Healthcare Provider Details

I. General information

NPI: 1871457069
Provider Name (Legal Business Name): HEIDI FAITH DONNELLY CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4155 MOORPARK AVE SUITE 20/21
SAN JOSE CA
95117
US

IV. Provider business mailing address

4155 MOORPARK AVE STE 21
SAN JOSE CA
95117-1714
US

V. Phone/Fax

Practice location:
  • Phone: 408-493-2333
  • Fax: 408-715-2200
Mailing address:
  • Phone: 408-493-2333
  • Fax: 408-715-2200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number43521
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: