Provider Demographics
NPI:1902939069
Name:DOHERTY, ALISA MARY (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:MARY
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:ALISA
Other - Middle Name:MARY
Other - Last Name:GRACEFFA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW, LCSW, CMSW
Mailing Address - Street 1:160 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:MAYNARD
Mailing Address - State:MA
Mailing Address - Zip Code:01754-1056
Mailing Address - Country:US
Mailing Address - Phone:978-495-1899
Mailing Address - Fax:
Practice Address - Street 1:705 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472
Practice Address - Country:US
Practice Address - Phone:857-304-8401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNCSW72131041C0700X
390200000X
MA1177051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program