Provider Demographics
NPI:1619015021
Name:MCDONAGH, JOHN MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:MCDONAGH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CARNEGIE AVENUE
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11724-2000
Mailing Address - Country:US
Mailing Address - Phone:631-427-6902
Mailing Address - Fax:631-427-6902
Practice Address - Street 1:2 CARNEGIE AVENUE
Practice Address - Street 2:
Practice Address - City:COLD SPRING HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11724-2000
Practice Address - Country:US
Practice Address - Phone:631-427-6902
Practice Address - Fax:631-427-6902
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0047851103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
5838OtherAMER BOARD PROF PSYCHOLOG
NY00625269Medicaid
NY00625269Medicaid