Healthcare Provider Details

I. General information

NPI: 1023939311
Provider Name (Legal Business Name): MATTHEW DOUGHERTY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 ELM PL
BROOKLYN NY
11201-5355
US

IV. Provider business mailing address

347 NOSTRAND AVE APT 4F
BROOKLYN NY
11216-4669
US

V. Phone/Fax

Practice location:
  • Phone: 718-802-0666
  • Fax:
Mailing address:
  • Phone: 732-232-4992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number131989
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: