Provider Demographics
NPI:1669016382
Name:DOUGHERTY, HEIDI M (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:M
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 BLUEBIRD HL
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-1450
Mailing Address - Country:US
Mailing Address - Phone:812-230-2925
Mailing Address - Fax:
Practice Address - Street 1:1001 SYCAMORE LN
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-1474
Practice Address - Country:US
Practice Address - Phone:317-501-6912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003252A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist