Provider Demographics
NPI:1982056271
Name:DONATH, LAURA (EDS)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DONATH
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 HEMLOCK RD
Mailing Address - Street 2:APT. 103
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-7960
Mailing Address - Country:US
Mailing Address - Phone:570-903-2592
Mailing Address - Fax:
Practice Address - Street 1:77 LILLEY AVE
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-9258
Practice Address - Country:US
Practice Address - Phone:570-888-7766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1875103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014423480001Medicaid