Provider Demographics
NPI:1679968283
Name:DONOVAN, SAMANTHA JOY (LPC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOY
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62663-0051
Mailing Address - Country:US
Mailing Address - Phone:217-883-2282
Mailing Address - Fax:309-403-1369
Practice Address - Street 1:5230 6TH STREET FRONTAGE RD E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5128
Practice Address - Country:US
Practice Address - Phone:217-585-1180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.010877101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional