Provider Demographics
NPI:1255953527
Name:DONNELLY, SUSAN C (MSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 N BROADWAY UNIT 205
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-6031
Mailing Address - Country:US
Mailing Address - Phone:248-515-7484
Mailing Address - Fax:
Practice Address - Street 1:191 N BROADWAY UNIT 205
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-6031
Practice Address - Country:US
Practice Address - Phone:248-515-7484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-10
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8891-1231041C0700X
MI68010180851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical