Provider Demographics
NPI:1750006649
Name:DONOVAN, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-6113
Mailing Address - Country:US
Mailing Address - Phone:850-503-6206
Mailing Address - Fax:
Practice Address - Street 1:1011 N 12TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-3306
Practice Address - Country:US
Practice Address - Phone:850-250-1441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH23014101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional