Healthcare Provider Details

I. General information

NPI: 1114570421
Provider Name (Legal Business Name): ROBERTO EZEQUIEL DONATI LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 HEALTHWAY DR
SALISBURY MD
21804-4469
US

IV. Provider business mailing address

PO BOX 1978
SALISBURY MD
21802-1978
US

V. Phone/Fax

Practice location:
  • Phone: 410-219-5483
  • Fax: 410-219-5486
Mailing address:
  • Phone: 410-749-1015
  • Fax: 410-749-0654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC11784
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: