Provider Demographics
NPI:1336484575
Name:DOUGHERTY, KATHLEEN MARY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials: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:PO BOX 480462
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-5320
Mailing Address - Country:US
Mailing Address - Phone:704-258-1724
Mailing Address - Fax:
Practice Address - Street 1:4208 ALDERSHOT CT
Practice Address - Street 2:APT. E
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5092
Practice Address - Country:US
Practice Address - Phone:704-258-1724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8977235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist