Provider Demographics
NPI:1174865182
Name:MCDONOUGH, STEPHEN (MFT INTERN)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1862 ELLIS ST
Mailing Address - Street 2:UNIT C
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-4022
Mailing Address - Country:US
Mailing Address - Phone:415-716-8447
Mailing Address - Fax:
Practice Address - Street 1:2323 HEARST AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1319
Practice Address - Country:US
Practice Address - Phone:510-548-7270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF66348101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health