Provider Demographics
NPI:1962552315
Name:DOHERTY, ROBERT PATRICK (LICSW)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:PATRICK
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 MYRTLE ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-6359
Mailing Address - Country:US
Mailing Address - Phone:508-405-0361
Mailing Address - Fax:508-405-0361
Practice Address - Street 1:24 MYRTLE ST
Practice Address - Street 2:SUITE D
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-6359
Practice Address - Country:US
Practice Address - Phone:508-405-0361
Practice Address - Fax:508-405-0361
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1119141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP23763Medicare ID - Type Unspecified