Provider Demographics
NPI:1346593100
Name:DOHERTY, LISA
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
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 1:41 TURTLE COVE LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3875
Mailing Address - Country:US
Mailing Address - Phone:631-421-0494
Mailing Address - Fax:
Practice Address - Street 1:41 TURTLE COVE LN
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3875
Practice Address - Country:US
Practice Address - Phone:631-421-0494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No174400000XOther Service ProvidersSpecialist