Provider Demographics
NPI:1669440343
Name:DOUGHERTY, WILLIAM G (OT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:G
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 241769
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99524-1769
Mailing Address - Country:US
Mailing Address - Phone:907-770-2380
Mailing Address - Fax:907-770-2341
Practice Address - Street 1:4100 LAKE OTIS PKWY
Practice Address - Street 2:STE 314
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5231
Practice Address - Country:US
Practice Address - Phone:907-274-2425
Practice Address - Fax:907-274-2428
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1089225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOT1089Medicaid
AK160064Medicare ID - Type Unspecified