Provider Demographics
NPI:1861846917
Name:DONNELLY, SUSAN ANN (COTA/L)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANN
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25220 MILITARY ROAD
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:MD
Mailing Address - Zip Code:21719
Mailing Address - Country:US
Mailing Address - Phone:240-367-1524
Mailing Address - Fax:
Practice Address - Street 1:56 WEST FREDERICK STREET
Practice Address - Street 2:
Practice Address - City:WALKERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21793
Practice Address - Country:US
Practice Address - Phone:301-898-4320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00608224Z00000X
PAOP002539L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant