Provider Demographics
NPI:1790800019
Name:O'DOUGHERTY, PETER (MS, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:O'DOUGHERTY
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 WOOD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10307-1350
Mailing Address - Country:US
Mailing Address - Phone:917-834-7412
Mailing Address - Fax:
Practice Address - Street 1:1515 LAMBERTS MILL RD
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-4763
Practice Address - Country:US
Practice Address - Phone:908-301-8259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00516800235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist