Provider Demographics
NPI:1679090203
Name:DOUGHERTY, BRIAN (LAC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 KENILWORTH DR
Mailing Address - Street 2:STE# 828
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204
Mailing Address - Country:US
Mailing Address - Phone:410-321-1388
Mailing Address - Fax:410-321-1388
Practice Address - Street 1:800 KENILWORTH DR
Practice Address - Street 2:STE# 828
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204
Practice Address - Country:US
Practice Address - Phone:410-321-1388
Practice Address - Fax:410-321-1388
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02428171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist