Provider Demographics
NPI:1982213757
Name:DOUGHERTY, MARY (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARY
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 1:29 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14546-1315
Mailing Address - Country:US
Mailing Address - Phone:704-995-0935
Mailing Address - Fax:
Practice Address - Street 1:1500 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3065
Practice Address - Country:US
Practice Address - Phone:585-697-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10144225X00000X
NY025656225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist