Healthcare Provider Details

I. General information

NPI: 1992713416
Provider Name (Legal Business Name): DONNA L BLACHE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DONNA L KNOWLTON LCSW

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 S HOSPITAL DR
MURPHYSBORO IL
62966-3333
US

IV. Provider business mailing address

P O BOX 577
CARTERVILLE IL
62918-0577
US

V. Phone/Fax

Practice location:
  • Phone: 618-687-3418
  • Fax: 618-687-1859
Mailing address:
  • Phone: 618-985-8221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149010444
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: