Provider Demographics
NPI:1952047854
Name:DOHERTY, KIM LEE
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:LEE
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-1649
Mailing Address - Country:US
Mailing Address - Phone:805-835-5729
Mailing Address - Fax:
Practice Address - Street 1:5575 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422
Practice Address - Country:US
Practice Address - Phone:805-461-6048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator