Provider Demographics
NPI:1104104793
Name:MCGOUGH, MARY BETH (DPT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:MCGOUGH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 OLD HUMBOLDT RD
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:TN
Mailing Address - Zip Code:38343-8417
Mailing Address - Country:US
Mailing Address - Phone:731-499-1290
Mailing Address - Fax:
Practice Address - Street 1:2107 PARK PLAZA DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-3937
Practice Address - Country:US
Practice Address - Phone:615-382-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist