Provider Demographics
NPI:1801465349
Name:DONNELLY-ANDROS, CHARLENE
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:DONNELLY-ANDROS
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 1:1103 N NEW YORK DR
Mailing Address - Street 2:
Mailing Address - City:N MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-1526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1103 N NEW YORK DR
Practice Address - Street 2:
Practice Address - City:N MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-1526
Practice Address - Country:US
Practice Address - Phone:516-592-9989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-20
Last Update Date:2021-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency