Provider Demographics
NPI:1578683058
Name:DOHERTY, LAURA (OTR)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12-24 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-2222
Mailing Address - Country:US
Mailing Address - Phone:201-300-2766
Mailing Address - Fax:
Practice Address - Street 1:536 RIDGE RD
Practice Address - Street 2:
Practice Address - City:CEDAR GROVE
Practice Address - State:NJ
Practice Address - Zip Code:07009-1611
Practice Address - Country:US
Practice Address - Phone:973-239-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00354500225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist