Healthcare Provider Details

I. General information

NPI: 1316314560
Provider Name (Legal Business Name): KATHY DONOVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2015
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 FILE ST
CLAYTON GA
30525-3023
US

IV. Provider business mailing address

236 FILE ST
CLAYTON GA
30525-3023
US

V. Phone/Fax

Practice location:
  • Phone: 706-212-2037
  • Fax: 801-437-2984
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW004066
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: