MEDICARE: IRENE M DOUGHERTY LPC

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	101YP2500X	Professional Counselor	PC003468	PA

General Provider Information

NPI Number	:	1104000157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRENE M DOUGHERTY LPC

Provider Business Mailing Address
First Line	:	407 FAIRMOUNT AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19123-2807
Country	:	US
Telephone Number	:	215-796-2481
Fax Number	:	215-627-6766

Provider Business Practice Location Address
First Line	:	407 FAIRMOUNT AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19123-2807
Country	:	US
Telephone Number	:	215-796-2481
Fax Number	:	215-627-6766

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

Provider Enumeration Date	:	12/27/2007
Last Update Date	:	12/27/2007

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