Healthcare Provider Details

I. General information

NPI: 1144862822
Provider Name (Legal Business Name): MARK DOHERTY LAC, LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2019
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 BROADWAY
MASSAPEQUA NY
11758-5027
US

IV. Provider business mailing address

623 BROADWAY
MASSAPEQUA NY
11758-5027
US

V. Phone/Fax

Practice location:
  • Phone: 516-781-1078
  • Fax:
Mailing address:
  • Phone: 516-781-1078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number007088
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number030560
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: