Provider Demographics
NPI:1235404815
Name:DOUGHERTY, REBECCA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:787 FISHER RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1203
Mailing Address - Country:US
Mailing Address - Phone:313-600-0021
Mailing Address - Fax:
Practice Address - Street 1:10300 W 8 MILE RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-2100
Practice Address - Country:US
Practice Address - Phone:248-632-2461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020654671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical