Healthcare Provider Details

I. General information

NPI: 1285691089
Provider Name (Legal Business Name): KATHLEEN THERESA MCGONAGLE PSY.D, RNCS PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 PLANTATION ST
WORCESTER MA
01605-2323
US

IV. Provider business mailing address

10 COLICUM DRIVE
CHARLTON MA
01507
US

V. Phone/Fax

Practice location:
  • Phone: 508-572-6033
  • Fax:
Mailing address:
  • Phone: 508-572-6033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number181899
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number9039
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: