Provider Demographics
NPI:1427182674
Name:DONNELLY, ELAINE M
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:M
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SMITHS GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:42171-8204
Mailing Address - Country:US
Mailing Address - Phone:270-901-5000
Mailing Address - Fax:
Practice Address - Street 1:380 SUWANNEE TRAIL STREET
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103
Practice Address - Country:US
Practice Address - Phone:270-901-5000
Practice Address - Fax:270-842-0054
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30604011Medicaid