MEDICARE: MARY DONNELLY MA, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	4003	NC
2	101YM0800X	Mental Health Counselor	9795	FL

General Provider Information

NPI Number	:	1205883386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY DONNELLY MA, LPC

Provider Business Mailing Address
First Line	:	PO BOX 152974
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33915-2974
Country	:	US
Telephone Number	:	239-989-9738
Fax Number	:	866-582-5875

Provider Business Practice Location Address
First Line	:	2804 DEL PRADO BLVD S STE 202-1
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33904-7252
Country	:	US
Telephone Number	:	239-989-9738
Fax Number	:	866-582-5875

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	03/13/2009

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