Provider Demographics
NPI:1831483874
Name:DOUGHERTY, SANDRA (LMSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8062 ORTONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-4456
Mailing Address - Country:US
Mailing Address - Phone:248-625-2970
Mailing Address - Fax:248-625-6829
Practice Address - Street 1:8062 ORTONVILLE RD
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-4456
Practice Address - Country:US
Practice Address - Phone:248-625-2970
Practice Address - Fax:248-625-6829
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801089986104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker