MEDICARE: SHANTAL 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	106S00000X	Behavior Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336677764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANTAL DONOVAN

Provider Business Mailing Address
First Line	:	5126 ASHLEY LAKE DR
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33437-3185
Country	:	US
Telephone Number	:	954-254-1186
Fax Number	:	800-766-3139

Provider Business Practice Location Address
First Line	:	5126 ASHLEY LAKE DR
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33437-3185
Country	:	US
Telephone Number	:	954-254-1186
Fax Number	:	800-766-3139

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

Provider Enumeration Date	:	05/30/2017
Last Update Date	:	07/21/2022

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Directions to “ SHANTAL DONOVAN ” Practice Location

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