Provider Demographics
NPI:1447637095
Name:DOHERTY, BREEANN
Entity type:Individual
Prefix:
First Name:BREEANN
Middle Name:
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 42ND ST
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-2752
Mailing Address - Country:US
Mailing Address - Phone:631-805-7658
Mailing Address - Fax:
Practice Address - Street 1:90 HENRY ST
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:NY
Practice Address - Zip Code:11096-2335
Practice Address - Country:US
Practice Address - Phone:718-327-3401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY841816728171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator