Provider Demographics
NPI:1013397561
Name:DONAHOE, CHARLENE
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:DONAHOE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 WYMAN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101
Mailing Address - Country:US
Mailing Address - Phone:815-909-0748
Mailing Address - Fax:
Practice Address - Street 1:235 WYMAN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101
Practice Address - Country:US
Practice Address - Phone:815-909-0748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-30
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$OtherINDEPENDENT CONTRACTOR PRELICENCED PROFESSIONAL BEHAVIORAL/MENTAL HEALTH