Provider Demographics
NPI:1174100192
Name:MCGONIGLE, KELSEY COLLEEN
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:COLLEEN
Last Name:MCGONIGLE
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 1:3835 CAPE LANDING DR APT T
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-1129
Mailing Address - Country:US
Mailing Address - Phone:215-287-3663
Mailing Address - Fax:
Practice Address - Street 1:3835 CAPE LANDING DR APT T
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-1129
Practice Address - Country:US
Practice Address - Phone:215-287-3663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBT-20-145344103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst