Provider Demographics
NPI:1386792000
Name:DONOVAN, TIMOTHY COULTER (MSW)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:COULTER
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 LIGHTHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21903-2529
Mailing Address - Country:US
Mailing Address - Phone:410-378-4940
Mailing Address - Fax:410-378-4905
Practice Address - Street 1:2324 W JOPPA RD
Practice Address - Street 2:SUITE 220
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4615
Practice Address - Country:US
Practice Address - Phone:410-583-2622
Practice Address - Fax:410-583-2949
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD085141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405QMedicare ID - Type Unspecified