Provider Demographics
NPI:1427171412
Name:MCDONOUGH, MARK (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 MANCHESTER AVE
Mailing Address - Street 2:STE 206
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-7902
Mailing Address - Country:US
Mailing Address - Phone:760-944-9647
Mailing Address - Fax:760-944-7491
Practice Address - Street 1:4405 MANCHESTER AVE
Practice Address - Street 2:STE 206
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-7902
Practice Address - Country:US
Practice Address - Phone:760-944-9647
Practice Address - Fax:760-944-7491
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 16390103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist