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General NPI Number Information
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NPI Number | 1902939069
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Entity Type | Individual
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Provider Name | ALISA MARY DOHERTY LICSW
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Gender | Female
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Dates
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Enumeration Date | 03/14/2007
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Last Update Date | 08/13/2018
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Provider Practice Location Address
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Address Line | 705 MOUNT AUBURN ST
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City | WATERTOWN
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State | MA
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Zip | 02472
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Country | US
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Telephone | 857-304-8401
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Fax |
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Provider Business Mailing Address
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Address Line | 160 SUMMER ST
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City | MAYNARD
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State | MA
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Zip | 01754-1056
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Country | US
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Telephone | 978-495-1899
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CSW7213
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 117705
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License Number State | MA
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