Provider Demographics
NPI:1104902402
Name:DONOVAN, ELAINE (MED LPE)
Entity type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:MED LPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 W WALNUT ST
Mailing Address - Street 2:SUITE 219
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:323 W WALNUT ST
Practice Address - Street 2:SUITE 219
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6760
Practice Address - Country:US
Practice Address - Phone:423-434-9943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPE0000011186101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN305-8435OtherBCBS OF TN