Healthcare Provider Details

I. General information

NPI: 1225674674
Provider Name (Legal Business Name): KIM MARIE DONOVAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11447 2ND ST STE 9B
ROSCOE IL
61073-9522
US

IV. Provider business mailing address

6426 TWIN DEER RUN
ROSCOE IL
61073-7239
US

V. Phone/Fax

Practice location:
  • Phone: 815-601-4673
  • Fax:
Mailing address:
  • Phone: 815-222-9061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.019932
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: