Provider Demographics
NPI:1407361249
Name:DOHERTY, COLIN J
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:J
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:COLIN
Other - Middle Name:J
Other - Last Name:DOHERTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ATC
Mailing Address - Street 1:1000 S QUENTIN RD
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-7018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 S QUENTIN RD
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-7018
Practice Address - Country:US
Practice Address - Phone:847-755-2790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0028832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer