Provider Demographics
NPI:1003506320
Name:IVERSON, DONNA LYNN
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:LYNN
Last Name:IVERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 1632
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4680 MONICA ST
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:32163-0516
Practice Address - Country:US
Practice Address - Phone:630-272-0546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
IL1490008541041C0700X
IL149008541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical