Provider Demographics
NPI:1861572497
Name:MARTIN, DONOVAN P (MA, NCC, LMHC)
Entity type:Individual
Prefix:MR
First Name:DONOVAN
Middle Name:P
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MA, NCC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 SAINT JOE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5000
Mailing Address - Country:US
Mailing Address - Phone:260-484-5599
Mailing Address - Fax:
Practice Address - Street 1:1910 SAINT JOE CENTER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5000
Practice Address - Country:US
Practice Address - Phone:260-484-5599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001739A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health