1750342796 NPI number — MRS. HEIDI EVE DONNELLAN LICSW

Table of content: MRS. HEIDI EVE DONNELLAN LICSW (NPI 1750342796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750342796 NPI number — MRS. HEIDI EVE DONNELLAN LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DONNELLAN
Provider First Name:
HEIDI
Provider Middle Name:
EVE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750342796
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
82 ANGELL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02048
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-337-9337
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
157 UNION ST
Provider Second Line Business Practice Location Address:
MARLBOROUGH HOSPITAL
Provider Business Practice Location Address City Name:
MARLBOROUGH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-486-5507
Provider Business Practice Location Address Fax Number:
508-229-1206
Provider Enumeration Date:
03/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  1022474 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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