Provider Demographics
NPI:1639953318
Name:DOUGHERTY, SERNIQUA
Entity Type:Individual
Prefix:
First Name:SERNIQUA
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SERNIQUA
Other - Middle Name:
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:170 E MOSHOLU PKWY S APT 9A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-1182
Mailing Address - Country:US
Mailing Address - Phone:917-536-5798
Mailing Address - Fax:
Practice Address - Street 1:170 E MOSHOLU PKWY S APT 9A
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-1182
Practice Address - Country:US
Practice Address - Phone:917-536-5798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst