1184031700 NPI number — MRS. LAURI DOUGHERTY LICENSED CLINICAL SO

Table of content: MRS. LAURI DOUGHERTY LICENSED CLINICAL SO (NPI 1184031700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184031700 NPI number — MRS. LAURI DOUGHERTY LICENSED CLINICAL SO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGHERTY
Provider First Name:
LAURI
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICENSED CLINICAL SO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184031700
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1014 PLEASANT HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06477-1116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-799-2187
Provider Business Mailing Address Fax Number:
203-378-4637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 CAPTAIN THOMAS BLVD
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
WEST HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06516-5951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-444-5159
Provider Business Practice Location Address Fax Number:
203-378-4637
Provider Enumeration Date:
07/15/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  005554 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 005554 . This is a "LICENSED CLINICAL SOCIAL WORKER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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