Provider Demographics
NPI:1407093628
Name:MONROE, DONOVAN JOSEPH (LMT)
Entity Type:Individual
Prefix:MR
First Name:DONOVAN
Middle Name:JOSEPH
Last Name:MONROE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1988 SE LADD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4737
Mailing Address - Country:US
Mailing Address - Phone:503-984-1963
Mailing Address - Fax:
Practice Address - Street 1:1988 SE LADD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4737
Practice Address - Country:US
Practice Address - Phone:503-984-1963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10214225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist