Provider Demographics
NPI:1497337836
Name:DONNELLY, MEGAN BERG (CT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:BERG
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17881 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-1047
Mailing Address - Country:US
Mailing Address - Phone:216-401-5798
Mailing Address - Fax:
Practice Address - Street 1:14701 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4115
Practice Address - Country:US
Practice Address - Phone:216-401-5798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2103125-TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health