Provider Demographics
NPI:1588838973
Name:DOHERTY, PATRICIA JUDITH (LICSW)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:JUDITH
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:PATRICIA
Other - Middle Name:JUDITH
Other - Last Name:LAWAICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:58 DUGWAY RD
Mailing Address - Street 2:
Mailing Address - City:WAITSFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05673-6116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:149 CHERRY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-3817
Practice Address - Country:US
Practice Address - Phone:866-843-1722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00008771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT089-0000877OtherVERMONT PROFESSIONAL REGULATION BOARD