Provider Demographics
NPI:1689038770
Name:DOUGHERTY, AMIE LYNN BOLES (PT, DPT)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:LYNN BOLES
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12001 INWOOD RD APT 1103
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-4003
Mailing Address - Country:US
Mailing Address - Phone:770-335-3461
Mailing Address - Fax:
Practice Address - Street 1:12001 INWOOD RD APT 1103
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-4003
Practice Address - Country:US
Practice Address - Phone:972-430-3126
Practice Address - Fax:972-525-9988
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12182782251P0200X
CO00138432251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics