Provider Demographics
NPI:1700013919
Name:DOHERTY, DEBORAH M (SPEECH PATHOLOGIST)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:M
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:SPEECH PATHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3713 W KAY POINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-6753
Mailing Address - Country:US
Mailing Address - Phone:417-523-3171
Mailing Address - Fax:
Practice Address - Street 1:639 W CHESTNUT EXPY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-3935
Practice Address - Country:US
Practice Address - Phone:417-523-7633
Practice Address - Fax:417-523-7795
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOM463366807Medicaid