Provider Demographics
NPI:1720371842
Name:DOHERTY, MARY DEBRA (DT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:DEBRA
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4456 N SAWYER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-4513
Mailing Address - Country:US
Mailing Address - Phone:773-539-3522
Mailing Address - Fax:
Practice Address - Street 1:4456 N SAWYER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-4513
Practice Address - Country:US
Practice Address - Phone:773-539-3522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-23
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist