Basic Information
| Provider Information | |||||||||
| NPI: | 1588916118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOHERTY | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 CRESTRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805253934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704949761 | ||||||||
| FaxNumber: | 9703469800 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 S SHIELDS ST | ||||||||
| Address2: | BUILDING K | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805261827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704944200 | ||||||||
| FaxNumber: | 9703469800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2012 | ||||||||
| LastUpdateDate: | 10/05/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW-9923048 | CO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.