Provider Demographics
NPI:1851034482
Name:DONOVAN, MATTHEW (COTA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 KELSEY RD APT 3
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-1662
Mailing Address - Country:US
Mailing Address - Phone:845-741-3008
Mailing Address - Fax:
Practice Address - Street 1:3374 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:MILLBROOK
Practice Address - State:NY
Practice Address - Zip Code:12545-5969
Practice Address - Country:US
Practice Address - Phone:845-677-3251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010691224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant