Provider Demographics
NPI:1598988586
Name:O'DOHERTY, EILEEN RYAN (M A, LADC I)
Entity Type:Individual
Prefix:MS
First Name:EILEEN
Middle Name:RYAN
Last Name:O'DOHERTY
Suffix:
Gender:F
Credentials:M A, LADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH YARMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02664-1814
Mailing Address - Country:US
Mailing Address - Phone:508-398-5155
Mailing Address - Fax:508-398-3478
Practice Address - Street 1:20 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH YARMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02664-1814
Practice Address - Country:US
Practice Address - Phone:508-398-5155
Practice Address - Fax:508-398-3478
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1383OtherLADC I