Provider Demographics
NPI:1669815643
Name:MCDONOUGH, TINA MARIE (LICSW)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14100 AILESBURY AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-2958
Mailing Address - Country:US
Mailing Address - Phone:612-239-6262
Mailing Address - Fax:
Practice Address - Street 1:5878 BLACKSHIRE PATH
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55076-1621
Practice Address - Country:US
Practice Address - Phone:612-239-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 103TA0400X, 103TB0200X, 103TC2200X, 103TH0004X, 103TP0814X, 103TP2701X, 101YM0800X
MN145341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1669815643Medicaid
MNVN000088953001Medicaid