MEDICARE: MR. CIUIN DOHERTY M.A., LMFT

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	106H00000X	Marriage & Family Therapist	112384	CA

General Provider Information

NPI Number	:	1710541966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CIUIN DOHERTY M.A., LMFT

Provider Business Mailing Address
First Line	:	511 RIALTO AVE APT 6
Second Line	:
City	:	VENICE
State	:	CA
Zip	:	90291-4285
Country	:	US
Telephone Number	:	310-866-1438
Fax Number	:

Provider Business Practice Location Address
First Line	:	3846 LYCEUM AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-4125
Country	:	US
Telephone Number	:	310-866-1438
Fax Number	:

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

Provider Enumeration Date	:	04/23/2019
Last Update Date	:	04/23/2019

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