Provider Demographics
NPI:1609138239
Name:DAUGHERTY, BRIEANNA PATRICE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:BRIEANNA
Middle Name:PATRICE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:BRIEANNA
Other - Middle Name:PATRICE
Other - Last Name:GESINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 W MAPLE ST STE 150
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-5805
Practice Address - Country:US
Practice Address - Phone:269-359-0898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012984101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1708146Medicaid