Healthcare Provider Details

I. General information

NPI: 1487006383
Provider Name (Legal Business Name): NICHOLE DONOVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 FORTUNE BLVD
MILFORD MA
01757-1750
US

IV. Provider business mailing address

22 ILEX RD
MARSHFIELD MA
02050-1773
US

V. Phone/Fax

Practice location:
  • Phone: 508-478-0207
  • Fax:
Mailing address:
  • Phone: 774-270-4496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: