Healthcare Provider Details

I. General information

NPI: 1205883386
Provider Name (Legal Business Name): MARY DONNELLY MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 03/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2804 DEL PRADO BLVD S STE 202-1
CAPE CORAL FL
33904-7252
US

IV. Provider business mailing address

PO BOX 152974
CAPE CORAL FL
33915-2974
US

V. Phone/Fax

Practice location:
  • Phone: 239-989-9738
  • Fax: 866-582-5875
Mailing address:
  • Phone: 239-989-9738
  • Fax: 866-582-5875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4003
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9795
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: