Provider Demographics
NPI:1245398585
Name:DOHERTY, GLORIA DIANE (LCSW)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:DIANE
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:DOHERTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:9601 LILE DR
Mailing Address - Street 2:SUITE 1050
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6321
Mailing Address - Country:US
Mailing Address - Phone:501-228-7400
Mailing Address - Fax:501-537-7412
Practice Address - Street 1:9601 LILE DR
Practice Address - Street 2:SUITE 1050
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6321
Practice Address - Country:US
Practice Address - Phone:501-228-7400
Practice Address - Fax:501-537-7412
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC10341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T203Medicare ID - Type Unspecified