Provider Demographics
NPI:1164732848
Name:DONAGHY, KEVAN LARES (LMSW)
Entity Type:Individual
Prefix:MR
First Name:KEVAN
Middle Name:LARES
Last Name:DONAGHY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 S EDWARDS AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-2912
Mailing Address - Country:US
Mailing Address - Phone:315-569-0339
Mailing Address - Fax:
Practice Address - Street 1:650 MADISON ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2319
Practice Address - Country:US
Practice Address - Phone:315-426-7694
Practice Address - Fax:315-426-6888
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0818401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical