Provider Demographics
NPI:1073078861
Name:DOHERTY, HOLLY MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:MARIE
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:HOLLY
Other - Middle Name:MARIE
Other - Last Name:WAXLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:904 TURNBERRY DR APT A
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-6103
Mailing Address - Country:US
Mailing Address - Phone:309-648-2031
Mailing Address - Fax:
Practice Address - Street 1:312 S WEST ST
Practice Address - Street 2:
Practice Address - City:GIBSON CITY
Practice Address - State:IL
Practice Address - Zip Code:60936-1659
Practice Address - Country:US
Practice Address - Phone:309-648-2031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013297111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology