Provider Demographics
NPI:1770823221
Name:DOUGHERTY, LISA SUE (OT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:SUE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 KELLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08520-5318
Mailing Address - Country:US
Mailing Address - Phone:609-651-0966
Mailing Address - Fax:
Practice Address - Street 1:300 CORPORATE CENTER DR
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-8736
Practice Address - Country:US
Practice Address - Phone:732-761-0088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-20
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00288300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist