Provider Demographics
NPI:1558382945
Name:DONNELLY, DIANE ELIZABETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:ELIZABETH
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3626 SACRAMENTO ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-1724
Mailing Address - Country:US
Mailing Address - Phone:415-563-3920
Mailing Address - Fax:415-456-2466
Practice Address - Street 1:3626 SACRAMENTO ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1724
Practice Address - Country:US
Practice Address - Phone:415-563-3920
Practice Address - Fax:415-456-2466
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7418103TC2200X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPL74180Medicare ID - Type Unspecified