Provider Demographics
NPI:1558907261
Name:DONOVAN, LISA A
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:GREENWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3 BAILEY WOODS RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:CT
Mailing Address - Zip Code:06234-2405
Mailing Address - Country:US
Mailing Address - Phone:860-774-6765
Mailing Address - Fax:
Practice Address - Street 1:62 PROVIDENCE PIKE STE E
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-2415
Practice Address - Country:US
Practice Address - Phone:860-805-0759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician