Provider Demographics
NPI:1982689451
Name:DOHERTY, MICHELE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:
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 1:25 EDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3401
Mailing Address - Country:US
Mailing Address - Phone:718-727-6056
Mailing Address - Fax:
Practice Address - Street 1:633 CLOVE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-2736
Practice Address - Country:US
Practice Address - Phone:718-727-5056
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO27974-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical