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General NPI Number Information
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NPI Number | 1689960221
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Entity Type | Individual
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Provider Name | MICHAEL C MCDONOUGH LICENSED CLINICALPSY
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Gender | Male
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Dates
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Enumeration Date | 06/22/2011
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Last Update Date | 04/12/2013
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Provider Practice Location Address
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Address Line | 112 BEECH STREET SUITE 1A
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City | GATE CITY
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State | VA
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Zip | 24251
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Country | US
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Telephone | 276-386-8012
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Fax |
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Provider Business Mailing Address
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Address Line | 1447 GLENMAR AVE
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City | MT CARMEL
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State | TN
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Zip | 37645-3026
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Country | US
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Telephone | 276-690-5535
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Fax | 276-386-2116
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2451
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License Number State | VA
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