Provider Demographics
NPI:1235492786
Name:DOUGHERTY, KATHLEEN HELEN
Entity Type:Individual
Prefix:MISS
First Name:KATHLEEN
Middle Name:HELEN
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:HELEN
Other - Last Name:HUNTINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14700 MANZANITA PARK RD
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223
Mailing Address - Country:US
Mailing Address - Phone:951-845-3155
Mailing Address - Fax:951-845-8412
Practice Address - Street 1:14700 MANZANITA PARK RD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223
Practice Address - Country:US
Practice Address - Phone:951-845-3155
Practice Address - Fax:951-845-8412
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49121106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist