Provider Demographics
NPI:1992713416
Name:BLACHE, DONNA L (LCSW)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:L
Last Name:BLACHE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:L
Other - Last Name:KNOWLTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:P O BOX 577
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0577
Mailing Address - Country:US
Mailing Address - Phone:618-985-8221
Mailing Address - Fax:
Practice Address - Street 1:7 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-3333
Practice Address - Country:US
Practice Address - Phone:618-687-3418
Practice Address - Fax:618-687-1859
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490104441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370966854002Medicaid
IL370966854005Medicaid
IL640701OtherPTAN MEDICARE
IL370966854005Medicaid
IL141848Medicare Oscar/Certification
IL370966854002Medicaid