Provider Demographics
NPI:1568616464
Name:DOHERTY, COLLEEN MARIE (PT)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:MARIE
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CHARLEVOIX DR SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7085
Mailing Address - Country:US
Mailing Address - Phone:610-334-4893
Mailing Address - Fax:800-325-1326
Practice Address - Street 1:888 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1668
Practice Address - Country:US
Practice Address - Phone:508-587-6556
Practice Address - Fax:508-588-1694
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18333225100000X
CAPT33051225100000X
HI2757225100000X
PAPT015950225100000X
NC10513225100000X
TX1178633225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist