Provider Demographics
NPI:1922371541
Name:MAIN, DONITA JEAN (MED)
Entity Type:Individual
Prefix:MS
First Name:DONITA
Middle Name:JEAN
Last Name:MAIN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3091 INDIAN RIVER DR NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-4359
Mailing Address - Country:US
Mailing Address - Phone:309-241-6000
Mailing Address - Fax:
Practice Address - Street 1:3091 INDIAN RIVER DR NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4359
Practice Address - Country:US
Practice Address - Phone:309-241-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor