Healthcare Provider Details

I. General information

NPI: 1689840407
Provider Name (Legal Business Name): MOLLY ELIZABETH DONOVAN L.I.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 07/16/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG. 390 N LOOP RD
FORT IRWIN CA
92310
US

IV. Provider business mailing address

3904 COMMANDERS LOOP
FORT IRWIN CA
92310-1519
US

V. Phone/Fax

Practice location:
  • Phone: 760-380-3198
  • Fax:
Mailing address:
  • Phone: 413-276-9363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113789
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: