Provider Demographics
NPI:1295715498
Name:DOUGHERTY, ELEANOR LOUISE (LMSW-C/MDCSW)
Entity type:Individual
Prefix:
First Name:ELEANOR
Middle Name:LOUISE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:LMSW-C/MDCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 N 26TH ST
Mailing Address - Street 2:PENSTAR OFFICE CENTER STE 103
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-2515
Mailing Address - Country:US
Mailing Address - Phone:906-233-9588
Mailing Address - Fax:906-217-2008
Practice Address - Street 1:1341 N 26TH ST
Practice Address - Street 2:PENSTAR OFFICE CENTER STE 103
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-2515
Practice Address - Country:US
Practice Address - Phone:906-233-9588
Practice Address - Fax:906-217-2008
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801069892101YA0400X, 101YM0800X, 101YP2500X, 1041C0700X, 106H00000X
WI3446- 123101YA0400X, 101YM0800X, 101YP2500X
WI3446-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
170082-000OtherMAGELLAN INDIVIDUAL ID
MI0897996OtherBCBSM PIN
MI8008979960OtherBCBSM PIN
MI0897996OtherBCBSM PIN