Provider Demographics
NPI:1104193671
Name:MCDONOUGH, TAI VICTORIA (DPT)
Entity Type:Individual
Prefix:
First Name:TAI
Middle Name:VICTORIA
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7907 OSTROW ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3635
Mailing Address - Country:US
Mailing Address - Phone:858-565-6910
Mailing Address - Fax:858-565-6911
Practice Address - Street 1:7907 OSTROW ST
Practice Address - Street 2:SUITE D
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3635
Practice Address - Country:US
Practice Address - Phone:858-565-6910
Practice Address - Fax:858-565-6911
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38488225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist