MEDICARE: THERESA SIOBHAN DONOHUE LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LC4516	MD

General Provider Information

NPI Number	:	1255684171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA SIOBHAN DONOHUE LCPC

Provider Business Mailing Address
First Line	:	804 LANDMARK DR STE 118
Second Line	:
City	:	GLEN BURNIE
State	:	MD
Zip	:	21061-4486
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	804 LANDMARK DR STE 118
Second Line	:
City	:	GLEN BURNIE
State	:	MD
Zip	:	21061-4486
Country	:	US
Telephone Number	:	410-863-7213
Fax Number	:	410-863-7205

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2012
Last Update Date	:	10/16/2012

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