Provider Demographics
NPI:1902042989
Name:MCDONNELL, MARY (LISW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:MCDONNELL
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 FAIRMOUNT BLVD
Mailing Address - Street 2:SUITE 323
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-3171
Mailing Address - Country:US
Mailing Address - Phone:216-229-4290
Mailing Address - Fax:330-425-4072
Practice Address - Street 1:2460 FAIRMOUNT BLVD
Practice Address - Street 2:SUITE 323
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-3171
Practice Address - Country:US
Practice Address - Phone:216-229-4290
Practice Address - Fax:330-425-4072
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10004457SUPV104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000307780OtherBLUE CROSS BLUE SHIELD