Provider Demographics
NPI:1063702496
Name:MCGONIGAL, CHRISTA ANN (LCSW-C)
Entity type:Individual
Prefix:
First Name:CHRISTA
Middle Name:ANN
Last Name:MCGONIGAL
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 LIBERTY HEIGHTS AVE
Mailing Address - Street 2:SUITE 4670
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-8019
Mailing Address - Country:US
Mailing Address - Phone:410-233-1088
Mailing Address - Fax:
Practice Address - Street 1:2401 LIBERTY HEIGHTS AVE
Practice Address - Street 2:SUITE 4670
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-8019
Practice Address - Country:US
Practice Address - Phone:410-233-1088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD105071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical