Provider Demographics
NPI:1750058913
Name:DONNELLY, SEAN PAULINE
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:PAULINE
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18501 GALE AVE
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91748-1329
Mailing Address - Country:US
Mailing Address - Phone:626-626-4997
Mailing Address - Fax:
Practice Address - Street 1:18501 GALE AVE
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91748-1329
Practice Address - Country:US
Practice Address - Phone:626-626-4997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
42073101YA0400X
CA42073167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)