Provider Demographics
NPI:1164767570
Name:DOUGHERTY, PAIGE LACEY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:LACEY
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 RED BIRCH RD
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:432 RED BIRCH RD
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1414
Practice Address - Country:US
Practice Address - Phone:410-919-7215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist