Provider Demographics
NPI:1255577201
Name:DONOVAN, ELIZABETH A (PHD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:A
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:OMAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:124 E 84TH ST APT 1B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0917
Mailing Address - Country:US
Mailing Address - Phone:917-475-6726
Mailing Address - Fax:
Practice Address - Street 1:124 E 84TH ST APT 1B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0917
Practice Address - Country:US
Practice Address - Phone:917-475-6726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-22
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY872574103TS0200X
NY021477103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH10024Medicaid
OH2846675Medicaid