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General NPI Number Information
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NPI Number | 1649567470
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Entity Type | Organization
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Legal Business Name | MARY A DONNELLY
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Dates
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Enumeration Date | 06/30/2011
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Last Update Date | 06/30/2011
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Provider Practice Location Address
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Address Line | 2804 DEL PRADO BLVD S STE 202-1
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City | CAPE CORAL
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State | FL
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Zip | 33904-7282
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Country | US
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Telephone | 239-989-9738
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 152974
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City | CAPE CORAL
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State | FL
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Zip | 33915-2974
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MARY DONNELLY
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Credential | LPC, LMHC
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Telephone | 704-453-3413
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 9795
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License Number State | FL
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