Provider Demographics
NPI:1710359781
Name:DOUGHTY, ACQUINNETTA
Entity type:Individual
Prefix:
First Name:ACQUINNETTA
Middle Name:
Last Name:DOUGHTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 W 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46407-3017
Mailing Address - Country:US
Mailing Address - Phone:219-333-7619
Mailing Address - Fax:
Practice Address - Street 1:490 W 23RD AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46407-3017
Practice Address - Country:US
Practice Address - Phone:219-333-7619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INLCAC87000707A101YA0400X
IN87000707A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)