Provider Demographics
NPI:1467647677
Name:DOUGHERTY, TAMARA MARIE (CSAC)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:MARIE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W RIVER DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53090-1567
Mailing Address - Country:US
Mailing Address - Phone:262-338-2717
Mailing Address - Fax:262-338-9767
Practice Address - Street 1:400 W RIVER DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53090-1567
Practice Address - Country:US
Practice Address - Phone:262-338-2717
Practice Address - Fax:262-338-9767
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15350-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39179600Medicaid