Healthcare Provider Details

I. General information

NPI: 1952007304
Provider Name (Legal Business Name): CHRISTINA MARIE DOUGHERTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10401 MONTGOMERY BLVD NE STE 2L
ALBUQUERQUE NM
87111-3844
US

IV. Provider business mailing address

1109 DASKALOS DR NE
ALBUQUERQUE NM
87123-1938
US

V. Phone/Fax

Practice location:
  • Phone: 858-504-7868
  • Fax:
Mailing address:
  • Phone: 858-504-7868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA MARIE DOUGHERTY
Title or Position: OWNER, CLINICIAN
Credential: LCSW
Phone: 858-504-7868