Provider Demographics
NPI:1942397625
Name:DOHERTY, NANCY SUE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:SUE
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 BROWNS LN
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7213
Mailing Address - Country:US
Mailing Address - Phone:870-972-4939
Mailing Address - Fax:870-972-4911
Practice Address - Street 1:2707 BROWNS LN
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7213
Practice Address - Country:US
Practice Address - Phone:870-972-4939
Practice Address - Fax:870-972-4911
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2495-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000539126OtherANTHEM
KY30605018Medicaid
KY00201012Medicare PIN
KY00205010Medicare PIN
KY00206010Medicare PIN
KY0763552Medicare PIN
KY0974725Medicare PIN
KY00199012Medicare PIN
KY0690956Medicare PIN
KY00200012Medicare PIN
KY0762256Medicare PIN
KY00207010Medicare PIN
KY000000539126OtherANTHEM