Provider Demographics
NPI:1275915795
Name:GONNELLA, MADELINE MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MADELINE
Middle Name:MARIE
Last Name:GONNELLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4024 STIRRUP CREEK DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-9464
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4024 STIRRUP CREEK DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-9464
Practice Address - Country:US
Practice Address - Phone:919-908-0395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-20
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0108851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical