Provider Demographics
NPI:1174186233
Name:MACDONOUGH, SUSAN RAE (LCPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RAE
Last Name:MACDONOUGH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:RAE
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1025 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4096
Mailing Address - Country:US
Mailing Address - Phone:217-222-6550
Mailing Address - Fax:217-277-2253
Practice Address - Street 1:1025 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4096
Practice Address - Country:US
Practice Address - Phone:217-222-6550
Practice Address - Fax:217-277-2253
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018036478101YP2500X
IL180013585101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health