Provider Demographics
NPI:1477756492
Name:DOUGHERTY, MICKAELLE (PHD)
Entity Type:Individual
Prefix:
First Name:MICKAELLE
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 W 106TH ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-3862
Mailing Address - Country:US
Mailing Address - Phone:929-204-3548
Mailing Address - Fax:
Practice Address - Street 1:19 W 106TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-3813
Practice Address - Country:US
Practice Address - Phone:813-890-8004
Practice Address - Fax:813-290-9691
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY47667452084P0800X
NY012401103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02362536Medicaid
NY02362536Medicaid
NYVM4341Medicare ID - Type Unspecified
NYP95370Medicare UPIN