Provider Demographics
NPI:1114640513
Name:DOUGHERTY, MATILDA MARIE (LGPC, NCC)
Entity Type:Individual
Prefix:
First Name:MATILDA
Middle Name:MARIE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:LGPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SMITHSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21783-1952
Mailing Address - Country:US
Mailing Address - Phone:240-422-3150
Mailing Address - Fax:
Practice Address - Street 1:319 W PATRICK ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4855
Practice Address - Country:US
Practice Address - Phone:301-640-5702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health