Provider Demographics
NPI:1033608781
Name:DOUGHERTY, PAIGE E (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:E
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-0220
Mailing Address - Country:US
Mailing Address - Phone:708-590-6663
Mailing Address - Fax:708-469-4100
Practice Address - Street 1:3004 N WATER ST STE C
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-1960
Practice Address - Country:US
Practice Address - Phone:217-233-0030
Practice Address - Fax:217-233-0031
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
IL070026601225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer