Provider Demographics
NPI:1871170290
Name:DONOVAN, HETTIE RACHELLE
Entity type:Individual
Prefix:
First Name:HETTIE
Middle Name:RACHELLE
Last Name:DONOVAN
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 1:5152 HEIL AVE APT 22
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3647
Mailing Address - Country:US
Mailing Address - Phone:714-756-0603
Mailing Address - Fax:
Practice Address - Street 1:5152 HEIL AVE APT 22
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-3647
Practice Address - Country:US
Practice Address - Phone:714-756-0603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77684225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist