Provider Demographics
NPI:1174864847
Name:DOUGHERTY, RENEE SHANNA
Entity Type:Individual
Prefix:MISS
First Name:RENEE
Middle Name:SHANNA
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 S COMMERCE ST
Mailing Address - Street 2:BUILDING B.
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-5519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2530 S COMMERCE ST
Practice Address - Street 2:BUILDING B.
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-5519
Practice Address - Country:US
Practice Address - Phone:580-223-2537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health