Provider Demographics
NPI:1912239955
Name:DONATHAN, GREG ALAN (LCSW)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:ALAN
Last Name:DONATHAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 MONTVALE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4290
Mailing Address - Country:US
Mailing Address - Phone:217-793-2770
Mailing Address - Fax:217-793-2887
Practice Address - Street 1:3050 MONTVALE DR
Practice Address - Street 2:SUITE D
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4290
Practice Address - Country:US
Practice Address - Phone:217-793-2770
Practice Address - Fax:217-793-2887
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490114521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical