Provider Demographics
NPI:1023615614
Name:DOUGHERTY, KELLY (LMSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 TRAP FALLS RD STE 120
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-7621
Mailing Address - Country:US
Mailing Address - Phone:203-816-6424
Mailing Address - Fax:203-513-8474
Practice Address - Street 1:2 TRAP FALLS RD STE 120
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-7621
Practice Address - Country:US
Practice Address - Phone:203-816-6424
Practice Address - Fax:203-513-8474
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical