MEDICARE: MS. CAROLYN RUTH DOHERTY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW16200	FL

General Provider Information

NPI Number	:	1407493737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROLYN RUTH DOHERTY LCSW

Provider Business Mailing Address
First Line	:	2554 LAKE DEBRA DR APT 25102
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32835-8711
Country	:	US
Telephone Number	:	781-243-9653
Fax Number	:

Provider Business Practice Location Address
First Line	:	2554 LAKE DEBRA DR APT 25102
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32835-8711
Country	:	US
Telephone Number	:	781-243-9653
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2019
Last Update Date	:	12/05/2019

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