Provider Demographics
NPI:1437539558
Name:DOUGHERTY, KLINT (ATC)
Entity Type:Individual
Prefix:
First Name:KLINT
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3428 BLOOMSBURY LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9520 E 520 S
Practice Address - Street 2:
Practice Address - City:WOLCOTTVILLE
Practice Address - State:IN
Practice Address - Zip Code:46795-9745
Practice Address - Country:US
Practice Address - Phone:269-437-7421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer