Provider Demographics
NPI:1336192418
Name:DOHERTY, ANN (LPC)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21283
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27120-1283
Mailing Address - Country:US
Mailing Address - Phone:336-655-5702
Mailing Address - Fax:336-724-2706
Practice Address - Street 1:936 W 4TH ST
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2564
Practice Address - Country:US
Practice Address - Phone:336-655-5702
Practice Address - Fax:336-724-2706
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2052101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102668Medicaid
NC1333FOtherBLUE CROSS/BLUE SHEILD