Provider Demographics
NPI:1952960106
Name:ISAAC-DOHERTY, MICHELLE VERONICA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:VERONICA
Last Name:ISAAC-DOHERTY
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 1:2783 E NORA DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2025
Mailing Address - Country:US
Mailing Address - Phone:215-805-4189
Mailing Address - Fax:
Practice Address - Street 1:774 E 2100 S STE 414
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-1863
Practice Address - Country:US
Practice Address - Phone:385-424-1361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10388767-3502104100000X
UT10388767-35011041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker