Provider Demographics
NPI:1013621382
Name:DOUGHERTY, KATHLEEN MARY
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 COOL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-2321
Mailing Address - Country:US
Mailing Address - Phone:317-696-1099
Mailing Address - Fax:
Practice Address - Street 1:1608 COOL CREEK DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46033-2321
Practice Address - Country:US
Practice Address - Phone:317-696-1099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program