Provider Demographics
NPI:1568954774
Name:MCDONOUGH, MARY TERESE (LICSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:TERESE
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 GRISWOLD ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1012
Mailing Address - Country:US
Mailing Address - Phone:617-497-0758
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5491
Practice Address - Country:US
Practice Address - Phone:617-632-8817
Practice Address - Fax:617-632-8830
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1052271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical