Provider Demographics
NPI:1740610567
Name:DOHERTY, SKYLER JOHN (LMT)
Entity Type:Individual
Prefix:
First Name:SKYLER
Middle Name:JOHN
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 HARRIS TRAIL RD APT 2G
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-4243
Mailing Address - Country:US
Mailing Address - Phone:912-484-2177
Mailing Address - Fax:912-748-1507
Practice Address - Street 1:1147 U.S. HWY 80
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322
Practice Address - Country:US
Practice Address - Phone:912-748-1506
Practice Address - Fax:912-748-1507
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT008933225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist