Provider Demographics
NPI:1396892089
Name:DONOVAN, GARY LEE (PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267-2031
Mailing Address - Country:US
Mailing Address - Phone:320-589-4648
Mailing Address - Fax:
Practice Address - Street 1:640 ATLANTIC AVE
Practice Address - Street 2:COUNSELING ASSOCIATES OF WC MINNESOTA
Practice Address - City:BENSON
Practice Address - State:MN
Practice Address - Zip Code:56215-1381
Practice Address - Country:US
Practice Address - Phone:320-843-3454
Practice Address - Fax:320-843-4692
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2839103T00000X
MNLICSW 62091041C0700X
MN782106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN25Y93DOOtherBCBS
MN943101014248OtherPREFERRED 1