Provider Demographics
NPI:1285691089
Name:MCGONAGLE, KATHLEEN THERESA (PSYD, RNCS PC)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:THERESA
Last Name:MCGONAGLE
Suffix:
Gender:F
Credentials:PSYD, RNCS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 COLICUM DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01507
Mailing Address - Country:US
Mailing Address - Phone:508-572-6033
Mailing Address - Fax:
Practice Address - Street 1:361 PLANTATION ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2323
Practice Address - Country:US
Practice Address - Phone:508-572-6033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA181899163WP0808X
MA9039103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANS0305Medicare ID - Type Unspecified