Provider Demographics
NPI:1154078681
Name:MCDONOUGH, RYAN CASEY
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:CASEY
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W COUNCIL ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-4209
Mailing Address - Country:US
Mailing Address - Phone:304-932-3501
Mailing Address - Fax:
Practice Address - Street 1:2300 W INNES ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2488
Practice Address - Country:US
Practice Address - Phone:704-637-4267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-48952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer