Provider Demographics
NPI:1104617984
Name:DOHERTY, ROSEMARIE
Entity type:Individual
Prefix:
First Name:ROSEMARIE
Middle Name:
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:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-0383
Mailing Address - Country:US
Mailing Address - Phone:619-301-2572
Mailing Address - Fax:
Practice Address - Street 1:560 COHASSET RD STE 175
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2460
Practice Address - Country:US
Practice Address - Phone:530-891-2810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-13
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95203830163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health