Provider Demographics
NPI:1437369824
Name:DONNELLY, CAROL M (PHD,LCP)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:M
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:PHD,LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N LAKE SHORE DR APT 3709
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3618
Mailing Address - Country:US
Mailing Address - Phone:312-520-1609
Mailing Address - Fax:
Practice Address - Street 1:618 LIBRARY PL
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2908
Practice Address - Country:US
Practice Address - Phone:847-733-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical