Provider Demographics
NPI:1477933828
Name:DOUGHERTY, RYAN (DPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
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 1:800 NW MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-9311
Mailing Address - Country:US
Mailing Address - Phone:816-524-7040
Mailing Address - Fax:816-524-7057
Practice Address - Street 1:800 NW MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-9311
Practice Address - Country:US
Practice Address - Phone:816-524-7040
Practice Address - Fax:816-524-7057
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015016309225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2015016309OtherMO LICENSE