Provider Demographics
NPI:1407339708
Name:DONNELLY, SUSAN BRADWAY (MPT, DPT, CCM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BRADWAY
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:MPT, DPT, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 AMHERST ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474-3409
Mailing Address - Country:US
Mailing Address - Phone:617-962-0553
Mailing Address - Fax:
Practice Address - Street 1:163 GORE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02141-1119
Practice Address - Country:US
Practice Address - Phone:617-499-8301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist