Provider Demographics
NPI:1114058922
Name:DONNELLY, DAN (LAC)
Entity Type:Individual
Prefix:MR
First Name:DAN
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 N MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3095
Mailing Address - Country:US
Mailing Address - Phone:406-756-6453
Mailing Address - Fax:406-756-8546
Practice Address - Street 1:1312 N MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3095
Practice Address - Country:US
Practice Address - Phone:406-756-6453
Practice Address - Fax:406-756-8546
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1049101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0320372Medicaid
MO760640OtherCHIP
MT0000076391OtherBLUE CROSS BLUE SHIELD