Provider Demographics
NPI:1902320179
Name:MCDONOUGH, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MOUNT VERNON ST STE 13
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1402
Mailing Address - Country:US
Mailing Address - Phone:781-910-9682
Mailing Address - Fax:
Practice Address - Street 1:1 MARKET ST STE 3
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1044
Practice Address - Country:US
Practice Address - Phone:781-592-0540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225200000X225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant