Healthcare Provider Details

I. General information

NPI: 1407310568
Provider Name (Legal Business Name): MARYBETH MCDONOUGH COUNSELOR TRAINEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3622 PROSPECT AVE E
CLEVELAND OH
44115-2704
US

IV. Provider business mailing address

1268 CHURCHILL RD
LYNDHURST OH
44124-1306
US

V. Phone/Fax

Practice location:
  • Phone: 216-431-4600
  • Fax:
Mailing address:
  • Phone: 440-799-9101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: