Provider Demographics
NPI:1902134448
Name:MCGOUGH, MARY ELIZABETH
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:MCGOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 18TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-8102
Mailing Address - Country:US
Mailing Address - Phone:206-235-4378
Mailing Address - Fax:
Practice Address - Street 1:1510 18TH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-8102
Practice Address - Country:US
Practice Address - Phone:206-235-4378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00013800225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist