Provider Demographics
NPI:1467715870
Name:MC DONNOUGH, CASEY DAWN (PTA, BS)
Entity Type:Individual
Prefix:MRS
First Name:CASEY
Middle Name:DAWN
Last Name:MC DONNOUGH
Suffix:
Gender:F
Credentials:PTA, BS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:53 COYOTE HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:VERGENNES
Mailing Address - State:IL
Mailing Address - Zip Code:62994-1438
Mailing Address - Country:US
Mailing Address - Phone:618-559-0275
Mailing Address - Fax:
Practice Address - Street 1:101 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:PINCKNEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62274-1034
Practice Address - Country:US
Practice Address - Phone:618-357-5935
Practice Address - Fax:618-357-6336
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004533225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant