Provider Demographics
NPI:1114977832
Name:MCTAGUE, KENNETH (PHD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MCTAGUE
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 1:2300 HIGHWAY 365
Mailing Address - Street 2:SUITE 620
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-6256
Mailing Address - Country:US
Mailing Address - Phone:409-729-0400
Mailing Address - Fax:866-573-8008
Practice Address - Street 1:2300 HIGHWAY 365
Practice Address - Street 2:SUITE 620
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627-6256
Practice Address - Country:US
Practice Address - Phone:409-729-0400
Practice Address - Fax:866-573-8008
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20970103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist