Basic Information
| Provider Information | |||||||||
| NPI: | 1376580555 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONOGHUE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 53 PAMEECHES PATH | ||||||||
| Address2: | |||||||||
| City: | EAST MORICHES | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119401313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319091823 | ||||||||
| FaxNumber: | 6313685433 | ||||||||
| Practice Location | |||||||||
| Address1: | SUITE 208A 3771 NESCONSET HWY. | ||||||||
| Address2: | |||||||||
| City: | SOUTH SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117201154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317519600 | ||||||||
| FaxNumber: | 6313695433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | R016427-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 02522021 | 05 | NY | MEDICAID |