Provider Demographics
NPI:1528537099
Name:DONOHO, CARLA SUE (LCSW)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:SUE
Last Name:DONOHO
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 1:17163 E LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-7451
Mailing Address - Country:US
Mailing Address - Phone:618-231-3314
Mailing Address - Fax:618-382-3239
Practice Address - Street 1:4243 LINCOLNSHIRE DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2157
Practice Address - Country:US
Practice Address - Phone:618-231-3314
Practice Address - Fax:618-382-3239
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.011890104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker