Provider Demographics
NPI:1972158608
Name:DIVITO, DONNA
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:DIVITO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2169 KINGWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-5058
Mailing Address - Country:US
Mailing Address - Phone:925-556-9435
Mailing Address - Fax:
Practice Address - Street 1:300 FOUNTAINGROVE PKWY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-5720
Practice Address - Country:US
Practice Address - Phone:707-566-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4614225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist