Provider Demographics
NPI:1346957461
Name:DETTLE, DONOVAN
Entity Type:Individual
Prefix:
First Name:DONOVAN
Middle Name:
Last Name:DETTLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 214
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95001-0214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 SOQUEL AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2301
Practice Address - Country:US
Practice Address - Phone:831-426-7322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor