Provider Demographics
NPI:1629127709
Name:DONNELLY, SUSAN ELIZABETH (PHD, LP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56730 CALUMET AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:CALUMET
Mailing Address - State:MI
Mailing Address - Zip Code:49913-2968
Mailing Address - Country:US
Mailing Address - Phone:906-337-6839
Mailing Address - Fax:906-337-0944
Practice Address - Street 1:56730 CALUMET AVE
Practice Address - Street 2:SUITE F
Practice Address - City:CALUMET
Practice Address - State:MI
Practice Address - Zip Code:49913-2968
Practice Address - Country:US
Practice Address - Phone:906-337-6839
Practice Address - Fax:906-337-0944
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI6301007915103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP32271Medicare UPIN