Provider Demographics
NPI:1548402738
Name:CLOUGHERTY, BRIAN P (MA, MDIV, LPC)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:P
Last Name:CLOUGHERTY
Suffix:
Gender:M
Credentials:MA, MDIV, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 MONTICELLO AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-3909
Mailing Address - Country:US
Mailing Address - Phone:919-672-8223
Mailing Address - Fax:919-401-0987
Practice Address - Street 1:4324 S ALSTON AVE STE 203
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-5296
Practice Address - Country:US
Practice Address - Phone:919-806-0009
Practice Address - Fax:919-806-1201
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 101YM0800X, 101YP1600X
NC7391101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6104213Medicaid