Provider Demographics
NPI:1316016611
Name:DONOVAN, LEO PAUL JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:PAUL
Last Name:DONOVAN
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:239 HAMILTON AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3480
Mailing Address - Country:US
Mailing Address - Phone:203-359-4560
Mailing Address - Fax:203-359-4913
Practice Address - Street 1:239 HAMILTON AVE APT 8
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3480
Practice Address - Country:US
Practice Address - Phone:203-359-4560
Practice Address - Fax:203-359-4913
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT560103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT680001131Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST