Healthcare Provider Details

I. General information

NPI: 1740762319
Provider Name (Legal Business Name): AILISH KATHLEEN DONOVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AILISH KATHLEEN MCSHEA

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SHATTUCK ST
WORCESTER MA
01605-3650
US

IV. Provider business mailing address

18 STEPPINGSTONE DR
HOLDEN MA
01520-1783
US

V. Phone/Fax

Practice location:
  • Phone: 508-769-2856
  • Fax:
Mailing address:
  • Phone: 774-232-1578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number117284
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: