Provider Demographics
NPI:1619115011
Name:DOHERTY, KIMBERLY A (SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:A
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-2808
Mailing Address - Country:US
Mailing Address - Phone:203-250-9663
Mailing Address - Fax:
Practice Address - Street 1:132 ELM ST
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-2808
Practice Address - Country:US
Practice Address - Phone:203-250-9663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003550235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist