Provider Demographics
NPI:1356838486
Name:DONAVAN, MANDY (LCSW)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:DONAVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1248 GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9317
Mailing Address - Country:US
Mailing Address - Phone:435-512-9492
Mailing Address - Fax:
Practice Address - Street 1:258 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5767
Practice Address - Country:US
Practice Address - Phone:435-512-9492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-14
Last Update Date:2018-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT698374535011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical