Provider Demographics
NPI:1730497686
Name:DOUGHERTY, STAYCE (LMHC)
Entity Type:Individual
Prefix:
First Name:STAYCE
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:STAYCE
Other - Middle Name:
Other - Last Name:FAVREAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:11 WOOD STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTHWICK
Mailing Address - State:MA
Mailing Address - Zip Code:01077
Mailing Address - Country:US
Mailing Address - Phone:413-207-7465
Mailing Address - Fax:
Practice Address - Street 1:11 WOOD STREET
Practice Address - Street 2:
Practice Address - City:SOUTHWICK
Practice Address - State:MA
Practice Address - Zip Code:01077
Practice Address - Country:US
Practice Address - Phone:413-478-8871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9130101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1300881Medicaid