Provider Demographics
NPI:1609965052
Name:DONNELLY, MAUREEN CECILIA II (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:CECILIA
Last Name:DONNELLY
Suffix:II
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:RAGHURAI
Other - Middle Name:KAUR
Other - Last Name:DONNELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:PO BOX 649
Mailing Address - Street 2:
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-0649
Mailing Address - Country:US
Mailing Address - Phone:505-929-8810
Mailing Address - Fax:
Practice Address - Street 1:CORNER OF ROUTE N12 AND N7
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504-0649
Practice Address - Country:US
Practice Address - Phone:929-729-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3049225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1780630491OtherGROUP NPI #
NM300521022Medicare UPIN