Provider Demographics
NPI:1285778514
Name:DONAHUE, MARY (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DONAHUE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 MACK AVENUE
Mailing Address - Street 2:BRASZA CENTER
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-745-1100
Mailing Address - Fax:313-745-0476
Practice Address - Street 1:261 MACK AVE
Practice Address - Street 2:BRASZA CENTER
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-1100
Practice Address - Fax:313-745-0476
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010041742251S0007X
2255A2300X
MI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer