Provider Demographics
NPI:1730711763
Name:DOHERTY, BROOKE L (LLMSW)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:L
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3395 AUSTRIAN PINE WAY APT 24C
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-2904
Mailing Address - Country:US
Mailing Address - Phone:269-352-0918
Mailing Address - Fax:
Practice Address - Street 1:519 S PARK ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5117
Practice Address - Country:US
Practice Address - Phone:269-383-0450
Practice Address - Fax:269-383-2066
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)