Provider Demographics
NPI:1366493769
Name:DONOVAN, PAUL BERNARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:BERNARD
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 OLD PECOS TRAIL, SUITE B
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-986-8866
Mailing Address - Fax:505-983-1891
Practice Address - Street 1:1640 OLD PECOS TRL
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4776
Practice Address - Country:US
Practice Address - Phone:505-986-8866
Practice Address - Fax:505-983-1891
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM675103TH0100X
NM#675103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMS3976.Medicaid
NMS3976.Medicaid