Provider Demographics
NPI:1821328436
Name:DONAHUE, LISA (MS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DONAHUE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-1536
Mailing Address - Country:US
Mailing Address - Phone:860-886-4850
Mailing Address - Fax:860-886-6567
Practice Address - Street 1:189 STORRS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1683
Practice Address - Country:US
Practice Address - Phone:860-456-1311
Practice Address - Fax:860-423-7933
Is Sole Proprietor?:No
Enumeration Date:2010-01-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001356106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist