Provider Demographics
NPI:1972189470
Name:DOHERTY, SHANNON LACEY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LACEY
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2807 DANIEL MCCALL DR APT 223
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-7151
Mailing Address - Country:US
Mailing Address - Phone:303-990-1945
Mailing Address - Fax:
Practice Address - Street 1:1000 LUMBERJACK DR
Practice Address - Street 2:
Practice Address - City:DIBOLL
Practice Address - State:TX
Practice Address - Zip Code:75941-9701
Practice Address - Country:US
Practice Address - Phone:936-829-5626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT83402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer