Provider Demographics
NPI:1326130576
Name:DONNELLY, MARYLOU (MA)
Entity Type:Individual
Prefix:MS
First Name:MARYLOU
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MORRIS ST STE 180
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-3835
Mailing Address - Country:US
Mailing Address - Phone:707-535-9879
Mailing Address - Fax:
Practice Address - Street 1:105 MORRIS ST STE 180
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3835
Practice Address - Country:US
Practice Address - Phone:707-535-9879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT22156103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist