Provider Demographics
NPI:1942290234
Name:DOUGHERTY, KATHERINE MARTIN (MSW)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:MARTIN
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 PENNYDOG CT
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-4168
Mailing Address - Country:US
Mailing Address - Phone:301-681-7224
Mailing Address - Fax:301-681-7224
Practice Address - Street 1:38 PENNYDOG CT
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-4168
Practice Address - Country:US
Practice Address - Phone:301-681-7224
Practice Address - Fax:301-681-7224
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD055691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD118631100Medicaid
16793500OtherMAGELLAN PRIVIDER NUMBER
DCA2960001OtherPROVIDER NUMBER
VA010110947Medicaid
646241Medicare ID - Type Unspecified