Provider Demographics
NPI:1093775033
Name:MCGAUGHEY, MARK C (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:MCGAUGHEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 E 21ST ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4443
Mailing Address - Country:US
Mailing Address - Phone:505-762-0212
Mailing Address - Fax:505-762-0660
Practice Address - Street 1:921 E 21ST ST
Practice Address - Street 2:SUITE D
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4443
Practice Address - Country:US
Practice Address - Phone:505-762-0212
Practice Address - Fax:505-762-0660
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM443103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39385OtherPRESBYTERIAN
NMN268OtherBLUE CROSS/BLUE SHIELD
NMN0203Medicaid