Provider Demographics
NPI:1366921934
Name:MCDONOUGH, MICHELE L (LCPC)
Entity type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:L
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2241 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-1322
Mailing Address - Country:US
Mailing Address - Phone:708-297-1723
Mailing Address - Fax:
Practice Address - Street 1:5080 N ELSTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2459
Practice Address - Country:US
Practice Address - Phone:773-506-3021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.011592101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional