Provider Demographics
NPI:1689840407
Name:DONOVAN, MOLLY ELIZABETH (LICSW)
Entity type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:ELIZABETH
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3904 COMMANDERS LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-1519
Mailing Address - Country:US
Mailing Address - Phone:413-276-9363
Mailing Address - Fax:
Practice Address - Street 1:BLDG. 390 N LOOP RD
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:760-380-3198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1137891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical