Provider Demographics
NPI:1952007304
Name:CHRISTINA MARIE DOUGHERTY
Entity Type:Organization
Organization Name:CHRISTINA MARIE DOUGHERTY
Other - Org Name:CHRISTINA DOUGHERTY LCSW LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:858-504-7868
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 1:1109 DASKALOS DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-1938
Practice Address - Country:US
Practice Address - Phone:858-504-7868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-06
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM6L2005OtherNM MEDICARE PTAN GROUP