Provider Demographics
NPI:1760851778
Name:DOHERTY, COURTNI DAWN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:COURTNI
Middle Name:DAWN
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:COURTNI
Other - Middle Name:
Other - Last Name:MUNDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 2ND ST SW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001
Mailing Address - Country:US
Mailing Address - Phone:253-237-3405
Mailing Address - Fax:253-679-0488
Practice Address - Street 1:110 2ND ST SW
Practice Address - Street 2:SUITE 110
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001
Practice Address - Country:US
Practice Address - Phone:253-237-3405
Practice Address - Fax:253-679-0488
Is Sole Proprietor?:No
Enumeration Date:2015-09-20
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60578339235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2070686Medicaid