Provider Demographics
NPI:1629099189
Name:O'DONOGHUE, JOHN W (LMFT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:W
Last Name:O'DONOGHUE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 BARRETT DR
Mailing Address - Street 2:SUITE 301-B
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6641
Mailing Address - Country:US
Mailing Address - Phone:919-341-2477
Mailing Address - Fax:
Practice Address - Street 1:3900 BARRETT DR
Practice Address - Street 2:SUITE 301-B
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6641
Practice Address - Country:US
Practice Address - Phone:919-341-2477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1114106H00000X
CAMFC 40935106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6105123Medicaid