MEDICARE: SEAN DOUGHERTY PC

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1558139238
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEAN DOUGHERTY PC

Provider Business Mailing Address
First Line	:	967 SPAULDING AVE SE STE E
Second Line	:
City	:	ADA
State	:	MI
Zip	:	49301-3703
Country	:	US
Telephone Number	:	616-504-1002
Fax Number	:

Provider Business Practice Location Address
First Line	:	967 SPAULDING AVE SE STE E
Second Line	:
City	:	ADA
State	:	MI
Zip	:	49301-3703
Country	:	US
Telephone Number	:	616-504-1002
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER
Name	:	SEAN DOUGHERTY
Credential	:	LLP
Telephone Number	:	616-504-1002

Provider Enumeration Date	:	12/13/2023
Last Update Date	:	12/13/2023

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Directions to “SEAN DOUGHERTY PC ” Practice Location

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