Provider Demographics
NPI:1225189178
Name:MCDONOUGH, MICHAL LEVINE (MED)
Entity type:Individual
Prefix:MS
First Name:MICHAL
Middle Name:LEVINE
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 LAMAR AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2335
Mailing Address - Country:US
Mailing Address - Phone:704-517-9866
Mailing Address - Fax:704-376-8677
Practice Address - Street 1:515 LAMAR AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2335
Practice Address - Country:US
Practice Address - Phone:704-517-9866
Practice Address - Fax:704-376-8677
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC969101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102234Medicaid