Provider Demographics
NPI:1316003551
Name:DONNELLY, KEVIN JOSEPH (PH D)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOSEPH
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 STRATFORD ST
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-2008
Mailing Address - Country:US
Mailing Address - Phone:617-982-7924
Mailing Address - Fax:617-983-7455
Practice Address - Street 1:1153 CENTRE ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-983-7924
Practice Address - Fax:617-983-7455
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1985103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW02154Medicare ID - Type Unspecified