Healthcare Provider Details

I. General information

NPI: 1194262352
Provider Name (Legal Business Name): COLLEEN ANN DOUGHERTY LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2017
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2632 PENNSYLVANIA ST NE SUITE E
ALBUQUERQUE NM
87110-3613
US

IV. Provider business mailing address

118 SYCAMORE ST NE APT 4
ALBUQUERQUE NM
87106-4665
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-4400
  • Fax: 505-242-4595
Mailing address:
  • Phone: 505-948-6958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0175641
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: