Provider Demographics
NPI:1255488631
Name:DONNELLY, LESLIE H (EDD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:H
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1627
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1627
Mailing Address - Country:US
Mailing Address - Phone:410-548-9148
Mailing Address - Fax:410-548-1048
Practice Address - Street 1:212 W MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-5006
Practice Address - Country:US
Practice Address - Phone:410-742-7160
Practice Address - Fax:410-630-7389
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2017-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03248103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD743301800Medicaid
MD457QMedicare ID - Type UnspecifiedMEDICARE