Provider Demographics
NPI:1851866941
Name:DOUGHERTY, VANESSA (OTR/L)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18685 MAIN ST STE 101-459
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1723
Mailing Address - Country:US
Mailing Address - Phone:714-697-1907
Mailing Address - Fax:714-464-4555
Practice Address - Street 1:2845 MESA VERDE DR E STE 9
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4858
Practice Address - Country:US
Practice Address - Phone:714-697-1907
Practice Address - Fax:714-464-4555
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT17769225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist