Provider Demographics
NPI:1740240431
Name:DOHERTY, TIMOTHY MICHAEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 LUCERNE LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-2916
Mailing Address - Country:US
Mailing Address - Phone:336-774-0379
Mailing Address - Fax:
Practice Address - Street 1:190 KIMEL PARK DR
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6946
Practice Address - Country:US
Practice Address - Phone:336-768-3296
Practice Address - Fax:336-760-5484
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0028631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical