Provider Demographics
NPI:1558828392
Name:DONNELLY, TRACIE MICHELLE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:MICHELLE
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 1:1733 MOONGLOW RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-6767
Mailing Address - Country:US
Mailing Address - Phone:618-335-6708
Mailing Address - Fax:
Practice Address - Street 1:1121 N 6TH ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1219
Practice Address - Country:US
Practice Address - Phone:618-283-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty