Provider Demographics
NPI:1316732837
Name:DOUGHERTY, COLLEEN MARIE (MS, CGC)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:DOUGHERTY
Suffix:
Gender:
Credentials:MS, CGC
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:MARIE
Other - Last Name:MCGILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CGC
Mailing Address - Street 1:PO BOX 112
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:CT
Mailing Address - Zip Code:06612-0112
Mailing Address - Country:US
Mailing Address - Phone:203-505-1255
Mailing Address - Fax:
Practice Address - Street 1:19 FLAT ROCK DR
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:CT
Practice Address - Zip Code:06612-1701
Practice Address - Country:US
Practice Address - Phone:203-505-1255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT41170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS