Provider Demographics
NPI:1720835432
Name:DOHERTY, PHILIP ANDREW
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:ANDREW
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 SHERMAN AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-4926
Mailing Address - Country:US
Mailing Address - Phone:206-512-4861
Mailing Address - Fax:
Practice Address - Street 1:7621 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2212
Practice Address - Country:US
Practice Address - Phone:773-234-0423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor