MEDICARE: SHANNAN DONOVAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-19-85229	OK

General Provider Information

NPI Number	:	1659938082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNAN DONOVAN

Provider Business Mailing Address
First Line	:	600 LIBERTY LN
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73034-9432
Country	:	US
Telephone Number	:	405-548-1029
Fax Number	:	817-549-3172

Provider Business Practice Location Address
First Line	:	600 LIBERTY LN
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73034-9432
Country	:	US
Telephone Number	:	405-548-1029
Fax Number	:	817-549-3172

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2019
Last Update Date	:	07/06/2020

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Directions to “ SHANNAN DONOVAN ” Practice Location

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