Provider Demographics
NPI:1336157528
Name:DONNELLY, CHANTAL LYNE (MPT)
Entity Type:Individual
Prefix:
First Name:CHANTAL
Middle Name:LYNE
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:CHANTAL
Other - Middle Name:LYNE
Other - Last Name:FYFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1800 CAMDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4910
Mailing Address - Country:US
Mailing Address - Phone:626-403-6429
Mailing Address - Fax:626-403-6429
Practice Address - Street 1:1942 HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4959
Practice Address - Country:US
Practice Address - Phone:626-403-6545
Practice Address - Fax:626-441-7660
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26069225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT26069BMedicare ID - Type Unspecified
CAP58258Medicare UPIN