1962593020 NPI number — MS. MICHELE JUDITH DOUGHERTY LCSW

Table of content: MS. MICHELE JUDITH DOUGHERTY LCSW (NPI 1962593020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962593020 NPI number — MS. MICHELE JUDITH DOUGHERTY LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGHERTY
Provider First Name:
MICHELE
Provider Middle Name:
JUDITH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MONTGOMERY
Provider Other First Name:
MICHELE
Provider Other Middle Name:
JUDITH
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962593020
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
37053 CHERRY STREET
Provider Second Line Business Mailing Address:
SUITE 204C
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94560-3785
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-739-0942
Provider Business Mailing Address Fax Number:
510-797-6261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
37053 CHERRY STREET
Provider Second Line Business Practice Location Address:
SUITE 204C
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94560-3785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-739-0942
Provider Business Practice Location Address Fax Number:
510-797-6261
Provider Enumeration Date:
09/27/2006

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: 1041C0700X , with the licence number:  LCS13019 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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