Healthcare Provider Details

I. General information

NPI: 1528078805
Provider Name (Legal Business Name): KATHLEEN GARVEY MCDONOUGH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 OAK ST
SPRINGVALE ME
04083-1926
US

IV. Provider business mailing address

7 POOL DR
WELLS ME
04090-6415
US

V. Phone/Fax

Practice location:
  • Phone: 207-432-2539
  • Fax:
Mailing address:
  • Phone: 207-351-0057
  • Fax: 207-646-8058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC6538
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier282750099
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: