Healthcare Provider Details

I. General information

NPI: 1740316389
Provider Name (Legal Business Name): ELIZABETH MARY DOHERTY L.I.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 E SUPERIOR ST SUITE 101
DULUTH MN
55802-2185
US

IV. Provider business mailing address

230 E SUPERIOR ST SUITE 101
DULUTH MN
55802-2185
US

V. Phone/Fax

Practice location:
  • Phone: 218-726-5433
  • Fax: 218-279-2844
Mailing address:
  • Phone: 218-726-5433
  • Fax: 218-279-2844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9522
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: