Healthcare Provider Details

I. General information

NPI: 1952607038
Provider Name (Legal Business Name): DIANE OLIVER DONAHUE BCBA, ITDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 06/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2569 SE SPRINGTREE PL
STUART FL
34997-8577
US

IV. Provider business mailing address

9150 SW 21ST DR
STUART FL
34997-7925
US

V. Phone/Fax

Practice location:
  • Phone: 772-223-6275
  • Fax: 772-223-6275
Mailing address:
  • Phone: 772-223-6275
  • Fax: 772-223-6275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-14-9625
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: