Basic Information
| Provider Information | |||||||||
| NPI: | 1396892089 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DONOVAN | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | PSYCHOLOGIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1009 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MORRIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562672031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205894648 | ||||||||
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| Practice Location | |||||||||
| Address1: | 640 ATLANTIC AVE | ||||||||
| Address2: | COUNSELING ASSOCIATES OF WC MINNESOTA | ||||||||
| City: | BENSON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562151381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208433454 | ||||||||
| FaxNumber: | 3208434692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP2839 | MN | X | Behavioral Health & Social Service Providers | Psychologist | 1041C0700X | LICSW 6209 | MN | X | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | 782 | MN | X | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 25Y93DO | 01 | MN | BCBS | OTHER | 943101014248 | 01 | MN | PREFERRED 1 | OTHER |