Healthcare Provider Details

I. General information

NPI: 1902939069
Provider Name (Legal Business Name): ALISA MARY DOHERTY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALISA MARY GRACEFFA LICSW, LCSW, CMSW

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 MOUNT AUBURN ST
WATERTOWN MA
02472
US

IV. Provider business mailing address

160 SUMMER ST
MAYNARD MA
01754-1056
US

V. Phone/Fax

Practice location:
  • Phone: 857-304-8401
  • Fax:
Mailing address:
  • Phone: 978-495-1899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW7213
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number117705
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: