Provider Demographics
NPI:1164191821
Name:DOUGHERTY, SAMANTHA (COTA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 BROOK LN
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17053-9500
Mailing Address - Country:US
Mailing Address - Phone:334-414-2189
Mailing Address - Fax:
Practice Address - Street 1:1200 GRUBB RD
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:PA
Practice Address - Zip Code:17078-3514
Practice Address - Country:US
Practice Address - Phone:717-838-5406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP009960224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant