Provider Demographics
NPI:1376580555
Name:DONOGHUE, JOHN MICHAEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MICHAEL
Last Name:DONOGHUE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:53 PAMEECHES PATH
Mailing Address - Street 2:
Mailing Address - City:EAST MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11940-1313
Mailing Address - Country:US
Mailing Address - Phone:631-909-1823
Mailing Address - Fax:631-368-5433
Practice Address - Street 1:SUITE 208A 3771 NESCONSET HWY.
Practice Address - Street 2:
Practice Address - City:SOUTH SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11720-1154
Practice Address - Country:US
Practice Address - Phone:631-751-9600
Practice Address - Fax:631-369-5433
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR016427-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02522021Medicaid
NY02522021Medicaid