Provider Demographics
NPI:1417137019
Name:DOUGHERTY, CAROL J (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:J
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 W 13TH ST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-7746
Mailing Address - Country:US
Mailing Address - Phone:212-807-1865
Mailing Address - Fax:212-337-0289
Practice Address - Street 1:230 W 13TH ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-7746
Practice Address - Country:US
Practice Address - Phone:212-807-1865
Practice Address - Fax:212-337-0289
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0400591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN73291Medicare PIN