Healthcare Provider Details

I. General information

NPI: 1295715498
Provider Name (Legal Business Name): ELEANOR LOUISE DOUGHERTY LMSW-C/M.DCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 01/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1341 N 26TH ST PENSTAR OFFICE CENTER STE 103
ESCANABA MI
49829-2515
US

IV. Provider business mailing address

1341 N 26TH ST PENSTAR OFFICE CENTER STE 103
ESCANABA MI
49829-2515
US

V. Phone/Fax

Practice location:
  • Phone: 906-233-9588
  • Fax: 906-217-2008
Mailing address:
  • Phone: 906-233-9588
  • Fax: 906-217-2008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6801069892
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3446- 123
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6801069892
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3446- 123
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6801069892
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3446- 123
License Number StateWI
# 7
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801069892
License Number StateMI
# 8
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3446-123
License Number StateWI
# 9
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number6801069892
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: