Provider Demographics
NPI:1770242349
Name:DONOVAN, KYLA KERRY (LCSW)
Entity Type:Individual
Prefix:
First Name:KYLA
Middle Name:KERRY
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 1:1980 LANCASTER LN APT 208
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-8570
Mailing Address - Country:US
Mailing Address - Phone:231-736-9847
Mailing Address - Fax:
Practice Address - Street 1:55 E LOOP RD STE 301
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-1938
Practice Address - Country:US
Practice Address - Phone:231-736-9847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1501028731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical