=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215112859
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONNA J. CONWELL MCAT, ADTR, NCC, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2008
-----------------------------------------------------
Last Update Date | 01/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 920 W CHESTER PIKE
-----------------------------------------------------
City | HAVERTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19083-4415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-544-2110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 920 W CHESTER PIKE
-----------------------------------------------------
City | HAVERTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19083-4415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-544-2110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | PC003221
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------