Healthcare Provider Details

I. General information

NPI: 1164732848
Provider Name (Legal Business Name): KEVAN LARES DONAGHY LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 10/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 MADISON ST SECOND FLOOR
SYRACUSE NY
13210-2319
US

IV. Provider business mailing address

165 S EDWARDS AVE
SYRACUSE NY
13206-2912
US

V. Phone/Fax

Practice location:
  • Phone: 315-426-7694
  • Fax: 315-426-6888
Mailing address:
  • Phone: 315-569-0339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number081840
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: