Provider Demographics
NPI:1811181464
Name:DONOVAN, THOMAS S (LCPC, LPHA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:LCPC, LPHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 N 6TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2502
Mailing Address - Country:US
Mailing Address - Phone:217-228-0543
Mailing Address - Fax:217-228-0543
Practice Address - Street 1:428 N 6TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2502
Practice Address - Country:US
Practice Address - Phone:217-228-0543
Practice Address - Fax:217-228-0543
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004945101YP2500X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist