Provider Demographics
NPI:1174182794
Name:DONNELLY, ANJERICA
Entity Type:Individual
Prefix:
First Name:ANJERICA
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 SE FEDERAL HWY STE 220
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-4556
Mailing Address - Country:US
Mailing Address - Phone:772-678-6704
Mailing Address - Fax:772-221-9969
Practice Address - Street 1:2400 SE FEDERAL HWY STE 220
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4556
Practice Address - Country:US
Practice Address - Phone:772-678-6704
Practice Address - Fax:772-221-9969
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-07
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-18-71693106S00000X
FL1-22-62959103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022577600Medicaid