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General NPI Number Information
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NPI Number | 1760079396
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Entity Type | Individual
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Provider Name | AMANDA ROSE DONNELLY PHD
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Gender | Female
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Dates
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Enumeration Date | 12/29/2020
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Last Update Date | 12/27/2022
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Provider Practice Location Address
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Address Line | 11855 ULYSSES ST NE
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City | BLAINE
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State | MN
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Zip | 55434-3947
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Country | US
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Telephone | 763-762-9241
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Fax |
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Provider Business Mailing Address
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Address Line | 10611 BALTIMORE ST NE UNIT 490412
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City | MINNEAPOLIS
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State | MN
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Zip | 55449-9930
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Country | US
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Telephone | 651-279-3963
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | CC00630
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | LP6790
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License Number State | MN
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