Provider Demographics
NPI:1053485797
Name:MCDONALD, BRIAN G (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:G
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 EWING ST
Mailing Address - Street 2:SUITE C-14
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-2757
Mailing Address - Country:US
Mailing Address - Phone:609-497-6440
Mailing Address - Fax:
Practice Address - Street 1:601 EWING ST
Practice Address - Street 2:SUITE C-14
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-2757
Practice Address - Country:US
Practice Address - Phone:609-497-6440
Practice Address - Fax:609-497-9243
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3483103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3483OtherPSYCHOLOGIST LICENSE
NJ673543Medicare ID - Type Unspecified