Organization
ADULT FAMILY & GROUP COUNSELING PLLC
Active
Organization
ADULT FAMILY & GROUP COUNSELING PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. ELEANOR LOUISE DOUGHERTY LMSW-CM,CAC 1, DCSW (PRESIDENT)
(906) 420-5844
Entity
Organization
Contact information
Practice address
1920 LAKE SHORE DR, MEMORIAL UNITED METHODIST CHURCH OFFICES, GLADSTONE, MI 49837-1249
(906) 420-5844
(906) 474-6010
Mailing address
10426 V.05 RD, PO BOX165, RAPID RIVER, MI 49878-9462
(906) 474-6010
(906) 474-6010
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
6801069892
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0897996
BCBSM INDIVIUAL PROVIDER PIN
MI
01
—
0P44870
MEDICARE GROUP #
—
01
—
1295715498
OWNER / PROVIDER NPI
MI
01
—
600073696
MAGELLAN GROUP/ORG #
—
01
—
8008979960
BCBSM ID
MI
Enumeration date
02/23/2007
Last updated
05/14/2013
Update your record
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