Provider Demographics
NPI:1952740607
Name:DONNELLY, BRIAN PATRICK
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:PATRICK
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 VINELAND ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2012
Mailing Address - Country:US
Mailing Address - Phone:781-801-2122
Mailing Address - Fax:
Practice Address - Street 1:237 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-3036
Practice Address - Country:US
Practice Address - Phone:781-801-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA043097170101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional