Healthcare Provider Details

I. General information

NPI: 1689938672
Provider Name (Legal Business Name): DONNA MARIE CASSELLA-JOHNSON LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

634 OAKWOOD ST
MINOOKA IL
60447-1229
US

IV. Provider business mailing address

634 OAKWOOD ST
MINOOKA IL
60447-1229
US

V. Phone/Fax

Practice location:
  • Phone: 815-467-5520
  • Fax: 815-353-0334
Mailing address:
  • Phone: 815-467-5520
  • Fax: 815-353-0334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180008263
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178006231
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: