MEDICARE: SEAN MICHAEL DOUGHERTY MA LLP

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	103T00000X	Psychologist	6301009294	MI

General Provider Information

NPI Number	:	1902841968
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SEAN MICHAEL DOUGHERTY MA LLP

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	:	616-719-4480

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	:	616-719-4480

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

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	12/13/2023

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