Provider Demographics
NPI:1538332705
Name:DOUGHERTY, JAMES ROBERT (PT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ROBERT
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10220 W FOREST HILL BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-9332
Mailing Address - Country:US
Mailing Address - Phone:561-753-5610
Mailing Address - Fax:561-795-8653
Practice Address - Street 1:10220 W FOREST HILL BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-9332
Practice Address - Country:US
Practice Address - Phone:561-753-5610
Practice Address - Fax:561-795-8653
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19254225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist