Provider Demographics
NPI:1164790663
Name:DOUGHERTY, TAMARA M (LCPC)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:M
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5020
Mailing Address - Country:US
Mailing Address - Phone:410-341-3420
Mailing Address - Fax:410-341-3397
Practice Address - Street 1:505 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5020
Practice Address - Country:US
Practice Address - Phone:410-341-3420
Practice Address - Fax:410-341-3397
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD609500300Medicaid