Provider Demographics
NPI:1447705488
Name:O'DONOVAN, MICHAEL SAMUEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SAMUEL
Last Name:O'DONOVAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 WOOD ST
Mailing Address - Street 2:
Mailing Address - City:NEW WILMINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:16142-1022
Mailing Address - Country:US
Mailing Address - Phone:724-656-8866
Mailing Address - Fax:724-946-2508
Practice Address - Street 1:450 WOOD ST
Practice Address - Street 2:
Practice Address - City:NEW WILMINGTON
Practice Address - State:PA
Practice Address - Zip Code:16142-1022
Practice Address - Country:US
Practice Address - Phone:724-656-8866
Practice Address - Fax:724-946-2508
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-016797103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPS-016797OtherPA STATE PSYCHOLOGY LICENSE