Provider Demographics
NPI:1235468802
Name:DOHERTY, STEFANIE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 BROCKLEY DR
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-2300
Mailing Address - Country:US
Mailing Address - Phone:518-424-0137
Mailing Address - Fax:
Practice Address - Street 1:46 BROCKLEY DR
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-2300
Practice Address - Country:US
Practice Address - Phone:518-424-0137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019698-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03661589Medicaid