Provider Demographics
NPI:1417132432
Name:DOUGHERTY, PATRICK JOHN (LP)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:JOHN
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 PRIOR AVE N
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-5165
Mailing Address - Country:US
Mailing Address - Phone:651-646-9638
Mailing Address - Fax:
Practice Address - Street 1:366 PRIOR AVE N
Practice Address - Street 2:SUITE 204
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-5165
Practice Address - Country:US
Practice Address - Phone:651-646-9638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 1483103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist