MEDICARE: ADULT FAMILY & GROUP COUNSELING PLLC

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	1041C0700X	Clinical Social Worker	6801069892	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	0P44870	OTHER		MEDICARE GROUP #

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1295715498	OTHER	MI	OWNER / PROVIDER NPI
3	0897996	OTHER	MI	BCBSM INDIVIUAL PROVIDER PIN
4	600073696	OTHER		MAGELLAN GROUP/ORG #
5	8008979960	OTHER	MI	BCBSM ID

General Provider Information

NPI Number	:	1518093871
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADULT FAMILY & GROUP COUNSELING PLLC

Provider Business Mailing Address
First Line	:	10426 V.05 RD
Second Line	:	PO BOX165
City	:	RAPID RIVER
State	:	MI
Zip	:	49878-9462
Country	:	US
Telephone Number	:	906-474-6010
Fax Number	:	906-474-6010

Provider Business Practice Location Address
First Line	:	1920 LAKE SHORE DR
Second Line	:	MEMORIAL UNITED METHODIST CHURCH OFFICES
City	:	GLADSTONE
State	:	MI
Zip	:	49837-1249
Country	:	US
Telephone Number	:	906-420-5844
Fax Number	:	906-474-6010

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. ELEANOR LOUISE DOUGHERTY
Credential	:	LMSW-CM,CAC 1, DCSW
Telephone Number	:	906-420-5844

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	05/14/2013

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