Provider Demographics
NPI:1356111488
Name:DOHERTY, PATRICIA D
Entity type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:D
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRISH
Other - Middle Name:
Other - Last Name:DOHERTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:60 KEEGANS LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-3046
Mailing Address - Country:US
Mailing Address - Phone:570-470-9291
Mailing Address - Fax:570-826-2235
Practice Address - Street 1:60 KEEGANS LN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-3046
Practice Address - Country:US
Practice Address - Phone:570-470-9291
Practice Address - Fax:570-826-2235
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency