Provider Demographics
NPI:1346676707
Name:DOUGHERTY, SHARON MARIE (RN, LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:MARIE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:RN, LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:994 W JERICHO TPKE
Mailing Address - Street 2:STE 202
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3234
Mailing Address - Country:US
Mailing Address - Phone:631-913-3526
Mailing Address - Fax:
Practice Address - Street 1:1250 WILLIAM FLOYD PARKWAY
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967
Practice Address - Country:US
Practice Address - Phone:631-913-3526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3709361163WP0807X
NYR0402211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent