Healthcare Provider Details

I. General information

NPI: 1861898066
Provider Name (Legal Business Name): SANDRA MCDONOUGH MS, CGC, LGC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2014
Last Update Date: 11/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 CENTRAL AVE SUITE 1230
ST PETERSBURG FL
33701-3857
US

IV. Provider business mailing address

360 CENTRAL AVE SUITE 1230
ST PETERSBURG FL
33701-3857
US

V. Phone/Fax

Practice location:
  • Phone: 800-975-4819
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number25MJ00005100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: