Provider Demographics
NPI:1205097938
Name:DOUGHERTY, CHRISTINA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MARIE
Last Name:DOUGHERTY
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 1:1109 DASKALOS DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-1938
Mailing Address - Country:US
Mailing Address - Phone:858-504-7868
Mailing Address - Fax:
Practice Address - Street 1:3705 W PICO BLVD # 790
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-3451
Practice Address - Country:US
Practice Address - Phone:858-504-7868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0188911041C0700X
FLSW78021041C0700X
NMSWB-2022-10131041C0700X
CA955141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB352029OtherMEDICARE CALIFORNIA PTAN
PA1033961110001Medicaid