Provider Demographics
NPI:1205334711
Name:DONATH, SAMUEL PAUL
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:PAUL
Last Name:DONATH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 HAVEN AVE STE 119
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-1011
Mailing Address - Country:US
Mailing Address - Phone:916-666-2759
Mailing Address - Fax:
Practice Address - Street 1:3705 HAVEN AVE STE 119
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-1011
Practice Address - Country:US
Practice Address - Phone:650-289-8603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT121544106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist