Provider Demographics
NPI:1134802168
Name:DOUGHERTY, BRANDON J (LSW)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:J
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:BRANDON
Other - Middle Name:JOHN
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LSW
Mailing Address - Street 1:807 W WHITE HORSE PIKE UNIT 95
Mailing Address - Street 2:
Mailing Address - City:COLOGNE
Mailing Address - State:NJ
Mailing Address - Zip Code:08213-1101
Mailing Address - Country:US
Mailing Address - Phone:609-829-8168
Mailing Address - Fax:
Practice Address - Street 1:807 W WHITE HORSE PIKE UNIT 95
Practice Address - Street 2:
Practice Address - City:COLOGNE
Practice Address - State:NJ
Practice Address - Zip Code:08213-1101
Practice Address - Country:US
Practice Address - Phone:609-829-8168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06787700225XM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health