Provider Demographics
NPI:1841443801
Name:DONAHUE, MARK (LICSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:DONAHUE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-6666
Mailing Address - Country:US
Mailing Address - Phone:802-451-1084
Mailing Address - Fax:
Practice Address - Street 1:130 BIRGE ST
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-6460
Practice Address - Country:US
Practice Address - Phone:802-254-3742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0890012591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical