Provider Demographics
NPI:1750846093
Name:DOHERTY, REBECCA E (LDO)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:E
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:
Other - Last Name:DOHERTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LDO
Mailing Address - Street 1:PO BOX 774
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-0134
Mailing Address - Country:US
Mailing Address - Phone:360-417-1244
Mailing Address - Fax:
Practice Address - Street 1:216 E 5TH ST STE A
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3008
Practice Address - Country:US
Practice Address - Phone:360-417-1244
Practice Address - Fax:360-417-1245
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1556156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAWA1410OtherWA TEAMSTERS