Basic Information
| Provider Information | |||||||||
| NPI: | 1467715870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MC DONNOUGH | ||||||||
| FirstName: | CASEY | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA, BS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 53 COYOTE HOLLOW LN | ||||||||
| Address2: | |||||||||
| City: | VERGENNES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629941438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185590275 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 101 N WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | PINCKNEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622741034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183575935 | ||||||||
| FaxNumber: | 6183576336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2012 | ||||||||
| LastUpdateDate: | 06/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 160004533 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.