Provider Demographics
NPI:1962593020
Name:DOUGHERTY, MICHELE JUDITH (LCSW)
Entity type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:JUDITH
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MICHELE
Other - Middle Name:JUDITH
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:37053 CHERRY STREET
Mailing Address - Street 2:SUITE 204C
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-3785
Mailing Address - Country:US
Mailing Address - Phone:510-739-0942
Mailing Address - Fax:510-797-6261
Practice Address - Street 1:37053 CHERRY STREET
Practice Address - Street 2:SUITE 204C
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-3785
Practice Address - Country:US
Practice Address - Phone:510-739-0942
Practice Address - Fax:510-797-6261
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS130191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical