Provider Demographics
NPI:1275421786
Name:DOUGHERTY, KRISTEN ANN
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ANN
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ANN
Other - Last Name:BRAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2861 CHESTER ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-1233
Mailing Address - Country:US
Mailing Address - Phone:516-528-1915
Mailing Address - Fax:
Practice Address - Street 1:2861 CHESTER ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1233
Practice Address - Country:US
Practice Address - Phone:516-528-1915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1114167252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency