Provider Demographics
NPI:1083964852
Name:DOUGHERTY, PATRICK OWEN (AAC)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:OWEN
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:AAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2073 OLYMPIC ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3413
Mailing Address - Country:US
Mailing Address - Phone:541-682-3550
Mailing Address - Fax:541-682-3551
Practice Address - Street 1:2411 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-5824
Practice Address - Country:US
Practice Address - Phone:541-682-7522
Practice Address - Fax:541-682-3276
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4550101YM0800X
WACG60416551101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health