MEDICARE: KERRY DONOVAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2355S0801X	Speech-Language Assistant	SP-1233-SA	MA
2	103K00000X	Behavior Analyst	1-18-33061	MA

General Provider Information

NPI Number	:	1174926885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRY DONOVAN

Provider Business Mailing Address
First Line	:	12 BAINBRIDGE RD
Second Line	:
City	:	WORCESTER
State	:	MA
Zip	:	01602-2212
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	176 WORCESTER PROVIDENCE TPKE
Second Line	:
City	:	SUTTON
State	:	MA
Zip	:	01590-1901
Country	:	US
Telephone Number	:	774-482-1110
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2014
Last Update Date	:	03/21/2022

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Directions to “ KERRY DONOVAN ” Practice Location

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