MEDICARE: MS. SALLY ANN DOUGHERTY LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	000432-1	NY

General Provider Information

NPI Number	:	1033130455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SALLY ANN DOUGHERTY LMHC

Provider Business Mailing Address
First Line	:	2760 COUNTY ROAD 30
Second Line	:
City	:	WELLSVILLE
State	:	NY
Zip	:	14895-9632
Country	:	US
Telephone Number	:	585-593-6323
Fax Number	:

Provider Business Practice Location Address
First Line	:	4220 STATE ROUTE 417 WEST
Second Line	:
City	:	WELLSVILLE
State	:	NY
Zip	:	14895-9332
Country	:	US
Telephone Number	:	585-593-6300
Fax Number	:	585-593-7071

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	07/08/2007

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