Provider Demographics
NPI:1285676155
Name:DONNELLY, MICHAEL (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 BEEBE RUN RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-5680
Mailing Address - Country:US
Mailing Address - Phone:856-453-1485
Mailing Address - Fax:
Practice Address - Street 1:313 BEEBE RUN RD
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-5680
Practice Address - Country:US
Practice Address - Phone:856-453-1485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00566300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist