Provider Demographics
NPI:1396224853
Name:DOUGHERTY, CONNOR JAMES (DPT)
Entity Type:Individual
Prefix:MR
First Name:CONNOR
Middle Name:JAMES
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220 132ND ST SE STE 101
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-8999
Mailing Address - Country:US
Mailing Address - Phone:425-686-7658
Mailing Address - Fax:425-341-9034
Practice Address - Street 1:110 110TH AVE NE STE 110
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-5840
Practice Address - Country:US
Practice Address - Phone:425-628-2072
Practice Address - Fax:425-341-9056
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60858127225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist