1689960221 NPI number — DR. MICHAEL C MCDONOUGH LICENSED CLINICALPSY

Table of content: DR. MICHAEL C MCDONOUGH LICENSED CLINICALPSY (NPI 1689960221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689960221 NPI number — DR. MICHAEL C MCDONOUGH LICENSED CLINICALPSY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDONOUGH
Provider First Name:
MICHAEL
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
LICENSED CLINICALPSY
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689960221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1447 GLENMAR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MT CARMEL
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37645-3026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-690-5535
Provider Business Mailing Address Fax Number:
276-386-2116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 BEECH STREET
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
GATE CITY
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-386-8012
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  2451 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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