Provider Demographics
NPI:1336780295
Name:DOHERTY, DEANNA ROSE (LMSW)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:ROSE
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:767 BROADWAY
Mailing Address - Street 2:PO BOX #1327
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003
Mailing Address - Country:US
Mailing Address - Phone:781-664-0647
Mailing Address - Fax:
Practice Address - Street 1:767 BROADWAY
Practice Address - Street 2:#1327
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:781-664-0647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
097883011041C0700X
NY1116181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical