Healthcare Provider Details

I. General information

NPI: 1821851601
Provider Name (Legal Business Name): RYAN KEITH DONOVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 02/05/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 PACIFIC AVE STE 305
TACOMA WA
98402-4434
US

IV. Provider business mailing address

510 NE 98TH ST APT 203
SEATTLE WA
98115-2105
US

V. Phone/Fax

Practice location:
  • Phone: 253-260-1511
  • Fax:
Mailing address:
  • Phone: 831-239-6219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: