Provider Demographics
NPI:1386007425
Name:CHRISTINA DOUGHERTY LCSW
Entity Type:Organization
Organization Name:CHRISTINA DOUGHERTY LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:424-777-0985
Mailing Address - Street 1:1206 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90069-2002
Mailing Address - Country:US
Mailing Address - Phone:813-270-9335
Mailing Address - Fax:
Practice Address - Street 1:1206 N CLARK ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90069-2002
Practice Address - Country:US
Practice Address - Phone:813-270-9335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-04
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 251B00000X, 261QR0405X, 101YA0400X
PACW018891251S00000X, 1041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1033961110001Medicaid
FLHZ741AMedicare PIN