Provider Demographics
NPI:1699881938
Name:DONNELLY, ANN MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:ANN MARIE
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3421
Mailing Address - Street 2:
Mailing Address - City:SHELL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93448-3421
Mailing Address - Country:US
Mailing Address - Phone:805-796-9059
Mailing Address - Fax:
Practice Address - Street 1:310 JAMES WAY STE 110
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-2877
Practice Address - Country:US
Practice Address - Phone:805-295-0387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11715103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY117150Medicaid
CACP11715Medicare ID - Type Unspecified
CAPSY117150Medicaid