Provider Demographics
NPI:1225674674
Name:DONOVAN, KIM MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6426 TWIN DEER RUN
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-7239
Mailing Address - Country:US
Mailing Address - Phone:815-222-9061
Mailing Address - Fax:
Practice Address - Street 1:11447 2ND ST STE 9B
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-9522
Practice Address - Country:US
Practice Address - Phone:815-601-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0199321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical