Provider Demographics
NPI:1790111078
Name:DOHERTY, PAMELA THYRA (MS)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:THYRA
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4744 70TH ST UNIT 5
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-4552
Mailing Address - Country:US
Mailing Address - Phone:619-303-0110
Mailing Address - Fax:
Practice Address - Street 1:4744 70TH ST UNIT 5
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-4552
Practice Address - Country:US
Practice Address - Phone:619-303-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool