Provider Demographics
NPI:1689995631
Name:DONOVAN, TINA M
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W NATIONAL RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-1963
Mailing Address - Country:US
Mailing Address - Phone:937-314-1659
Mailing Address - Fax:
Practice Address - Street 1:210 W NATIONAL RD
Practice Address - Street 2:SUITE 2
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-9361
Practice Address - Country:US
Practice Address - Phone:937-314-1659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE1700003101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health