Healthcare Provider Details

I. General information

NPI: 1306547625
Provider Name (Legal Business Name): AUDREY DONOVAN MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 08/13/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 POPLAR LN
HUNLOCK CREEK PA
18621-5037
US

IV. Provider business mailing address

21 POPLAR LN
HUNLOCK CREEK PA
18621-5037
US

V. Phone/Fax

Practice location:
  • Phone: 570-974-4653
  • Fax:
Mailing address:
  • Phone: 570-974-4653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC018456
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: