Provider Demographics
NPI:1285641977
Name:DOHERTY, JAMES PATRICK (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:PATRICK
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 RAYBROOK ST
Mailing Address - Street 2:STE 303
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7717
Mailing Address - Country:US
Mailing Address - Phone:616-464-1747
Mailing Address - Fax:616-464-1748
Practice Address - Street 1:2020 RAYBROOK ST
Practice Address - Street 2:STE 303
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7717
Practice Address - Country:US
Practice Address - Phone:616-464-1747
Practice Address - Fax:616-464-1748
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011612103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP37740Medicare PIN