Provider Demographics
NPI:1962031401
Name:MCDONOUGH, ELIZABETH (MFT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 LAS GALLINAS AVE # 161
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3618
Mailing Address - Country:US
Mailing Address - Phone:510-292-7370
Mailing Address - Fax:
Practice Address - Street 1:1811 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-1969
Practice Address - Country:US
Practice Address - Phone:510-292-7370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42310106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty