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General NPI Number Information
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NPI Number | 1215390646
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Entity Type | Individual
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Provider Name | MARY MCDONAGH
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Gender | Female
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Dates
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Enumeration Date | 04/02/2016
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Last Update Date | 04/02/2016
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Provider Practice Location Address
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Address Line | 710 S ATLANTIC ST
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City | DILLON
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State | MT
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Zip | 59725-3511
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Country | US
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Telephone | 617-283-8509
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Fax |
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Provider Business Mailing Address
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Address Line | 100 W GLENDALE ST APT 2
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City | DILLON
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State | MT
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Zip | 59725-2478
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Country | US
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Telephone | 617-283-8509
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | ATR-LAT-LIC-1225
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License Number State | MT
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