Provider Demographics
NPI:1073952461
Name:VESTAL, DONNA M
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:M
Last Name:VESTAL
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 1:7000 TRAIN STATION WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40272-4663
Mailing Address - Country:US
Mailing Address - Phone:502-387-8714
Mailing Address - Fax:
Practice Address - Street 1:7000 TRAIN STATION WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-4663
Practice Address - Country:US
Practice Address - Phone:502-387-8714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY000071985103K00000X, 171M00000X, 222Q00000X, 235500000X
KYYPAS1987225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist