Provider Demographics
NPI:1174814123
Name:DOUGHERTY, THOMAS E JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:DOUGHERTY
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 S STRATFORD RD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1823
Mailing Address - Country:US
Mailing Address - Phone:336-323-1616
Mailing Address - Fax:
Practice Address - Street 1:514 S STRATFORD RD
Practice Address - Street 2:STE 306
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1823
Practice Address - Country:US
Practice Address - Phone:336-323-1616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC193101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral