Provider Demographics
NPI:1760924450
Name:PATRICIA DOHERTY, LICSW, PLC
Entity Type:Organization
Organization Name:PATRICIA DOHERTY, LICSW, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:JUDITH
Authorized Official - Last Name:DOHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:802-825-6910
Mailing Address - Street 1:1205 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05408-2804
Mailing Address - Country:US
Mailing Address - Phone:802-489-5665
Mailing Address - Fax:
Practice Address - Street 1:1205 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05408-2804
Practice Address - Country:US
Practice Address - Phone:802-489-5665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT89.00008771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1023503Medicaid