Provider Demographics
NPI:1134696198
Name:DOHERTY, CRYSTAL M
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:M
Last Name:DOHERTY
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:PO BOX 1018
Mailing Address - Street 2:
Mailing Address - City:CARIBOU
Mailing Address - State:ME
Mailing Address - Zip Code:04736-1018
Mailing Address - Country:US
Mailing Address - Phone:207-498-6431
Mailing Address - Fax:207-492-3181
Practice Address - Street 1:1 EDGEMONT DR
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-2036
Practice Address - Country:US
Practice Address - Phone:207-764-3319
Practice Address - Fax:207-768-5377
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor