Provider Demographics
NPI:1407169683
Name:MCDONOUGH, MICHAEL (LMSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5204 WILSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1449
Mailing Address - Country:US
Mailing Address - Phone:631-723-3362
Mailing Address - Fax:631-723-3365
Practice Address - Street 1:31 E MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-1816
Practice Address - Country:US
Practice Address - Phone:631-723-3362
Practice Address - Fax:631-723-3365
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032070-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY032070-1OtherLICENSE