Provider Demographics
NPI:1528366820
Name:DONNELLY, GINA MARIA (BA;JD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIA
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:BA;JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9081 WATER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:MI
Mailing Address - Zip Code:48166-9581
Mailing Address - Country:US
Mailing Address - Phone:734-644-1466
Mailing Address - Fax:313-638-2470
Practice Address - Street 1:9081 WATER RIDGE DR
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:MI
Practice Address - Zip Code:48166-9581
Practice Address - Country:US
Practice Address - Phone:734-644-1466
Practice Address - Fax:313-638-2470
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst