Provider Demographics
NPI:1710936141
Name:DONNER, EDWARD J (PHD)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:J
Last Name:DONNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3601 30TH AVE
Mailing Address - Street 2:SUITE LL1
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1695
Mailing Address - Country:US
Mailing Address - Phone:262-657-9777
Mailing Address - Fax:262-657-9785
Practice Address - Street 1:3601 30TH AVE
Practice Address - Street 2:SUITE LL1
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1695
Practice Address - Country:US
Practice Address - Phone:262-657-9777
Practice Address - Fax:262-657-9785
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2007-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI2142057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39755100Medicaid