Provider Demographics
NPI:1194005181
Name:DOCHERTY, SHANNON RAE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RAE
Last Name:DOCHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 1/2 S DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-3533
Mailing Address - Country:US
Mailing Address - Phone:716-868-5732
Mailing Address - Fax:
Practice Address - Street 1:444 N LARCHMONT BLVD STE 109
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004
Practice Address - Country:US
Practice Address - Phone:716-868-5732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81272101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health