Provider Demographics
NPI:1215599766
Name:MCDONOUGH, STEPHANIE RITA (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RITA
Last Name:MCDONOUGH
Suffix:
Gender:F
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1021 MOREHEAD MEDICAL DR
Practice Address - Street 2:STE A
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2990
Practice Address - Country:US
Practice Address - Phone:980-442-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6023103T00000X
FLPY10525103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist