Provider Demographics
NPI:1518093871
Name:ADULT FAMILY & GROUP COUNSELING PLLC
Entity Type:Organization
Organization Name:ADULT FAMILY & GROUP COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW-CM,CAC 1, DCSW
Authorized Official - Phone:906-420-5844
Mailing Address - Street 1:10426 V.05 RD
Mailing Address - Street 2:PO BOX165
Mailing Address - City:RAPID RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49878-9462
Mailing Address - Country:US
Mailing Address - Phone:906-474-6010
Mailing Address - Fax:906-474-6010
Practice Address - Street 1:1920 LAKE SHORE DR
Practice Address - Street 2:MEMORIAL UNITED METHODIST CHURCH OFFICES
Practice Address - City:GLADSTONE
Practice Address - State:MI
Practice Address - Zip Code:49837-1249
Practice Address - Country:US
Practice Address - Phone:906-420-5844
Practice Address - Fax:906-474-6010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010698921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1295715498OtherOWNER / PROVIDER NPI
0P44870OtherMEDICARE GROUP #
MI0897996OtherBCBSM INDIVIUAL PROVIDER PIN
600073696OtherMAGELLAN GROUP/ORG #
MI8008979960OtherBCBSM ID
MI8008979960OtherBCBSM ID
0P44870OtherMEDICARE GROUP #