Provider Demographics
NPI:1871033522
Name:MCDONNELL, MARY (LAC, DLAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MCDONNELL
Suffix:
Gender:F
Credentials:LAC, DLAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 49TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-2239
Mailing Address - Country:US
Mailing Address - Phone:510-428-2222
Mailing Address - Fax:510-428-2222
Practice Address - Street 1:342 49TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2239
Practice Address - Country:US
Practice Address - Phone:510-428-2222
Practice Address - Fax:510-428-2222
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 3092405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional