Provider Demographics
NPI:1619350063
Name:DONOVAN, TERESE R (LMT, MMP)
Entity type:Individual
Prefix:
First Name:TERESE
Middle Name:R
Last Name:DONOVAN
Suffix:
Gender:
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:643 MARLBERRY PL
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-7474
Mailing Address - Country:US
Mailing Address - Phone:702-497-2838
Mailing Address - Fax:
Practice Address - Street 1:127 S WATER ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-7221
Practice Address - Country:US
Practice Address - Phone:702-497-2838
Practice Address - Fax:702-497-2838
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT.307225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist