1295715498 NPI number — ELEANOR LOUISE DOUGHERTY LMSW-C/M.DCSW

Table of content: ELEANOR LOUISE DOUGHERTY LMSW-C/M.DCSW (NPI 1295715498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295715498 NPI number — ELEANOR LOUISE DOUGHERTY LMSW-C/M.DCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGHERTY
Provider First Name:
ELEANOR
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW-C/M.DCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295715498
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1341 N 26TH ST
Provider Second Line Business Mailing Address:
PENSTAR OFFICE CENTER STE 103
Provider Business Mailing Address City Name:
ESCANABA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49829-2515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-233-9588
Provider Business Mailing Address Fax Number:
906-217-2008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1341 N 26TH ST
Provider Second Line Business Practice Location Address:
PENSTAR OFFICE CENTER STE 103
Provider Business Practice Location Address City Name:
ESCANABA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49829-2515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-233-9588
Provider Business Practice Location Address Fax Number:
906-217-2008
Provider Enumeration Date:
01/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  6801069892 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: 3446- 123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 6801069892 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 3446- 123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 6801069892 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 3446- 123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 6801069892 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: 3446-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 6801069892 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 170082-000 . This is a "MAGELLAN INDIVIDUAL ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0897996 . This is a "BCBSM PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 8008979960 . This is a "BCBSM PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".