Provider Demographics
NPI:1538630538
Name:DOHERTY, MONIQUE NICOLE (MSW LCSW)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:NICOLE
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 RIVER STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-2226
Mailing Address - Country:US
Mailing Address - Phone:802-886-4500
Mailing Address - Fax:805-886-4560
Practice Address - Street 1:51 FAIRVIEW STREET
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-6629
Practice Address - Country:US
Practice Address - Phone:802-254-6028
Practice Address - Fax:802-254-7501
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MA225794104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker