Healthcare Provider Details

I. General information

NPI: 1306191069
Provider Name (Legal Business Name): SHANE PATRICK DONOHUE P.C., LCDC-III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WELLINGTON PL
CINCINNATI OH
45219-1736
US

IV. Provider business mailing address

3425 KATIES GREEN CT
CINCINNATI OH
45211-2342
US

V. Phone/Fax

Practice location:
  • Phone: 513-621-3600
  • Fax:
Mailing address:
  • Phone: 513-518-1675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number111126
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC0900153
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC0900153
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberC0900153
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: