MEDICARE: MARY ELIZABETH DONOVAN MA, CCC-SLP

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	235Z00000X	Speech-Language Pathologist	19415	FL

General Provider Information

NPI Number	:	1720807126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELIZABETH DONOVAN MA, CCC-SLP

Provider Business Mailing Address
First Line	:	10804 WICKER PARK PL
Second Line	:
City	:	PALMETTO
State	:	FL
Zip	:	34221-1146
Country	:	US
Telephone Number	:	229-421-8116
Fax Number	:

Provider Business Practice Location Address
First Line	:	3030 6TH ST S
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33705-3720
Country	:	US
Telephone Number	:	727-894-8719
Fax Number	:

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

Provider Enumeration Date	:	10/03/2024
Last Update Date	:	10/03/2024

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