Provider Demographics
NPI:1407258080
Name:DONNELLY, BRETT
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30910
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93130-0910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6586 PICASSO RD
Practice Address - Street 2:
Practice Address - City:ISLA VISTA
Practice Address - State:CA
Practice Address - Zip Code:93117-4651
Practice Address - Country:US
Practice Address - Phone:805-699-6668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26685103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical