Provider Demographics
NPI:1518057900
Name:DOUGHERTY, MARYELLEN (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:MARYELLEN
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:MISS
Other - First Name:MARYELLEN
Other - Middle Name:
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:203 E BALTIMORE PIKE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3433
Mailing Address - Country:US
Mailing Address - Phone:610-565-0670
Mailing Address - Fax:610-565-7706
Practice Address - Street 1:203 E BALTIMORE PIKE
Practice Address - Street 2:SUITE 2
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3433
Practice Address - Country:US
Practice Address - Phone:610-565-0670
Practice Address - Fax:610-565-7706
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT018385225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1928216OtherBC/BS PIN
PA2799524000OtherKEYSTONE PIN
PAP00430771OtherMEDICARE RAILROAD PIN
PA2799524000OtherPERSONAL CHOICE PIN
PAP00430771OtherMEDICARE RAILROAD PIN