Provider Demographics
NPI:1821204538
Name:MCGONIGAL, JAMES JR (BC-HIS)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:MCGONIGAL
Suffix:JR
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 CROWN POINT RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-8878
Mailing Address - Country:US
Mailing Address - Phone:802-885-3399
Mailing Address - Fax:
Practice Address - Street 1:162 PARK ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-3036
Practice Address - Country:US
Practice Address - Phone:802-885-3399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT063-0000040237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006764Medicaid