Provider Demographics
NPI:1326162777
Name:MCGONIGLE, MARY A (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:A
Last Name:MCGONIGLE
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 1:2366 EASTLAKE AVE E STE 439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3392
Mailing Address - Country:US
Mailing Address - Phone:206-323-7742
Mailing Address - Fax:
Practice Address - Street 1:2366 EASTLAKE AVE E STE 439
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3392
Practice Address - Country:US
Practice Address - Phone:206-323-7742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY1922103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
20-4956959OtherTAX IDENTIFICATION NUMBER
PY1922OtherPSYCHOLOGIST-STATE OF WA