Provider Demographics
NPI:1063734168
Name:DONOVAN, MELISSA YVONNE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:YVONNE
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:YVONNE
Other - Last Name:PONDEXTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:4 SUMMER LAKE WAY
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4144
Mailing Address - Country:US
Mailing Address - Phone:678-860-2196
Mailing Address - Fax:
Practice Address - Street 1:110 PIPEMAKERS CIR STE 115
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4168
Practice Address - Country:US
Practice Address - Phone:912-988-1526
Practice Address - Fax:912-988-1537
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007363235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist