Provider Demographics
NPI:1215390646
Name:MCDONAGH, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MCDONAGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W GLENDALE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:MT
Mailing Address - Zip Code:59725-2478
Mailing Address - Country:US
Mailing Address - Phone:617-283-8509
Mailing Address - Fax:
Practice Address - Street 1:710 S ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725-3511
Practice Address - Country:US
Practice Address - Phone:617-283-8509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-02
Last Update Date:2016-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTATR-LAT-LIC-12252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer