Provider Demographics
NPI:1740316389
Name:DOHERTY, ELIZABETH MARY (LICSW)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:MARY
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E SUPERIOR ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2185
Mailing Address - Country:US
Mailing Address - Phone:218-726-5433
Mailing Address - Fax:218-279-2844
Practice Address - Street 1:230 E SUPERIOR ST
Practice Address - Street 2:SUITE 101
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2185
Practice Address - Country:US
Practice Address - Phone:218-726-5433
Practice Address - Fax:218-279-2844
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9522101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6229497Medicare UPIN
MN363R9DOMedicare UPIN