Provider Demographics
NPI:1013194166
Name:DAUGHERTY, CARRIE E (FAODP)
Entity Type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:E
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:FAODP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12501 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-3243
Mailing Address - Country:US
Mailing Address - Phone:313-865-1580
Mailing Address - Fax:313-865-1582
Practice Address - Street 1:12501 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3243
Practice Address - Country:US
Practice Address - Phone:313-865-1580
Practice Address - Fax:313-865-1582
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP23520Medicare PIN