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General NPI Number Information
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NPI Number | 1518093871
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Entity Type | Organization
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Legal Business Name | ADULT FAMILY & GROUP COUNSELING PLLC
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Dates
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Enumeration Date | 02/23/2007
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Last Update Date | 05/14/2013
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Provider Practice Location Address
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Address Line | 1920 LAKE SHORE DR MEMORIAL UNITED METHODIST CHURCH OFFICES
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City | GLADSTONE
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State | MI
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Zip | 49837-1249
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Country | US
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Telephone | 906-420-5844
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Fax | 906-474-6010
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Provider Business Mailing Address
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Address Line | 10426 V.05 RD PO BOX165
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City | RAPID RIVER
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State | MI
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Zip | 49878-9462
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Country | US
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Telephone | 906-474-6010
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Fax | 906-474-6010
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. ELEANOR LOUISE DOUGHERTY
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Credential | LMSW-CM,CAC 1, DCSW
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Telephone | 906-420-5844
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801069892
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License Number State | MI
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