Healthcare Provider Details

I. General information

NPI: 1265128730
Provider Name (Legal Business Name): PORTIA DOUGHTY LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2023
Last Update Date: 12/24/2025
Certification Date: 12/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 WEST D.L. INGRAM AVE.
CANNON AFB NM
88103
US

IV. Provider business mailing address

224 WEST D.L. INGRAM AVE.
CANNON AFB NM
88103
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-1108
  • Fax:
Mailing address:
  • Phone: 575-784-1108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC019277
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: