Provider Demographics
NPI:1477532265
Name:DOHERTY, JOHN G (DCSW,LCSW-C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:G
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:DCSW,LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10612 AUGUST CT
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:MD
Mailing Address - Zip Code:21795-1442
Mailing Address - Country:US
Mailing Address - Phone:301-223-5995
Mailing Address - Fax:
Practice Address - Street 1:510 BUTLER AVE
Practice Address - Street 2:VETERANS AFFAIRS MEDICAL CENTER
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-9990
Practice Address - Country:US
Practice Address - Phone:304-263-0811
Practice Address - Fax:304-262-1390
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD058881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical