Provider Demographics
NPI:1750342796
Name:DONNELLAN, HEIDI EVE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:EVE
Last Name:DONNELLAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 ANGELL ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048
Mailing Address - Country:US
Mailing Address - Phone:508-337-9337
Mailing Address - Fax:
Practice Address - Street 1:157 UNION ST
Practice Address - Street 2:MARLBOROUGH HOSPITAL
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752
Practice Address - Country:US
Practice Address - Phone:508-486-5507
Practice Address - Fax:508-229-1206
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1022474104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADUP06590Medicare ID - Type Unspecified