Provider Demographics
NPI:1891917050
Name:DONOGHUE, CAROLYN D (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:D
Last Name:DONOGHUE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 STILLMAN RD.
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2832
Mailing Address - Country:US
Mailing Address - Phone:216-228-3500
Mailing Address - Fax:216-228-5818
Practice Address - Street 1:13425 DETROIT AVENUE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4608
Practice Address - Country:US
Practice Address - Phone:216-228-3500
Practice Address - Fax:216-228-5818
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2497103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDOCP22571Medicare ID - Type UnspecifiedPSYCHOLOGIST