Provider Demographics
NPI:1417373895
Name:DONNELLY, MICHAEL SCOTT (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CHERRY BLOSSOM LN
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-4235
Mailing Address - Country:US
Mailing Address - Phone:352-205-1024
Mailing Address - Fax:
Practice Address - Street 1:102 CHERRY BLOSSOM LN
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-4235
Practice Address - Country:US
Practice Address - Phone:352-205-1024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT26412225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist