Healthcare Provider Details

I. General information

NPI: 1790001584
Provider Name (Legal Business Name): LISA ANNE DONNELLAN LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2010
Last Update Date: 04/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 PROFESSIONAL PARK DR SUITE 400
MOORESVILLE NC
28117-5599
US

IV. Provider business mailing address

134 PROFESSIONAL PARK DR SUITE 400
MOORESVILLE NC
28117-5599
US

V. Phone/Fax

Practice location:
  • Phone: 704-661-1009
  • Fax: 704-664-1029
Mailing address:
  • Phone: 704-661-1009
  • Fax: 704-664-1029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7776A
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: