MEDICARE: MR. MARK THOMAS MCGONIGLE LCSW

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	1041C0700X	Clinical Social Worker	2003019074	MO

General Provider Information

NPI Number	:	1689616559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK THOMAS MCGONIGLE LCSW

Provider Business Mailing Address
First Line	:	222 W GREGORY BLVD
Second Line	:	STE 310
City	:	KANSAS CITY
State	:	MO
Zip	:	64114-1127
Country	:	US
Telephone Number	:	816-822-0200
Fax Number	:	816-895-5210

Provider Business Practice Location Address
First Line	:	217 E 63RD ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64113-2224
Country	:	US
Telephone Number	:	816-822-0200
Fax Number	:	816-444-6425

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

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	03/06/2017

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