Provider Demographics
NPI:1487051280
Name:DOUGHTY, SAMANTHA (CADC, MHRT-CSP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DOUGHTY
Suffix:
Gender:F
Credentials:CADC, MHRT-CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 ACADEMY ST STE 3
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-3183
Mailing Address - Country:US
Mailing Address - Phone:207-554-2352
Mailing Address - Fax:207-554-2351
Practice Address - Street 1:180 ACADEMY ST STE 2
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-3183
Practice Address - Country:US
Practice Address - Phone:207-764-3319
Practice Address - Fax:207-768-5377
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MECAC7409101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1487051280Medicaid