MEDICARE: KAITLIN DOHERTY LSW, SCHOOLCOUNSELOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YS0200X	School Counselor		OH
2	104100000X	Social Worker		OH

General Provider Information

NPI Number	:	1164825196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLIN DOHERTY LSW, SCHOOLCOUNSELOR

Provider Business Mailing Address
First Line	:	8580 NORTHWOOD DR
Second Line	:
City	:	BROADVIEW HTS
State	:	OH
Zip	:	44147-3420
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8580 NORTHWOOD DR
Second Line	:
City	:	BROADVIEW HTS
State	:	OH
Zip	:	44147-3420
Country	:	US
Telephone Number	:	440-554-2716
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2014
Last Update Date	:	10/05/2014

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