Provider Demographics
NPI:1235407941
Name:DOUGHERTY, KELLY THERESA (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:THERESA
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 1:281 FAIR STREET
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512
Mailing Address - Country:US
Mailing Address - Phone:845-228-2300
Mailing Address - Fax:
Practice Address - Street 1:281 FAIR ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-6140
Practice Address - Country:US
Practice Address - Phone:845-228-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02016061-1235Z00000X
NY020161-1235Z00000X
NY0201061-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist