Provider Demographics
NPI:1326394313
Name:DONNELLY, MICHAEL (MED)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 WOODROW WILSON CT APT 56
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4462
Mailing Address - Country:US
Mailing Address - Phone:617-839-2631
Mailing Address - Fax:
Practice Address - Street 1:8 WOODROW WILSON CT APT 56
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-4462
Practice Address - Country:US
Practice Address - Phone:617-839-2631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor