Provider Demographics
NPI:1861853657
Name:DONNELLY, JUSTIN (MS)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 QUITA CIR APT B
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-4440
Mailing Address - Country:US
Mailing Address - Phone:615-955-1729
Mailing Address - Fax:
Practice Address - Street 1:135 QUITA CIR APT B
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-4440
Practice Address - Country:US
Practice Address - Phone:615-955-1729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
TN171M00000X
TN000-1205175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator