Provider Demographics
NPI:1407849870
Name:DOHERTY, EDWARD M (AT,C)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:M
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 PATCH HILL LN
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03055-4155
Mailing Address - Country:US
Mailing Address - Phone:603-672-1302
Mailing Address - Fax:
Practice Address - Street 1:350 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-2656
Practice Address - Country:US
Practice Address - Phone:617-484-4410
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer