Provider Demographics
NPI:1821344136
Name:DOUGHTY, LAURA ANN (LLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:DOUGHTY
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 PORT SHELDON ST
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-9337
Mailing Address - Country:US
Mailing Address - Phone:616-206-4499
Mailing Address - Fax:
Practice Address - Street 1:300 68TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-6927
Practice Address - Country:US
Practice Address - Phone:616-559-5897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014746103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist