Provider Demographics
NPI:1689960221
Name:MCDONOUGH, MICHAEL C (LICENSED CLINICALPSY)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:C
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:LICENSED CLINICALPSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1447 GLENMAR AVE
Mailing Address - Street 2:
Mailing Address - City:MT CARMEL
Mailing Address - State:TN
Mailing Address - Zip Code:37645-3026
Mailing Address - Country:US
Mailing Address - Phone:276-690-5535
Mailing Address - Fax:276-386-2116
Practice Address - Street 1:112 BEECH STREET
Practice Address - Street 2:SUITE 1A
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251
Practice Address - Country:US
Practice Address - Phone:276-386-8012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2451103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical