Provider Demographics
NPI:1184167355
Name:O'DOHERTY, MARY JUDE
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JUDE
Last Name:O'DOHERTY
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 1:30403 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-1739
Mailing Address - Country:US
Mailing Address - Phone:216-509-6089
Mailing Address - Fax:
Practice Address - Street 1:24525 HILLIARD BLVD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-3518
Practice Address - Country:US
Practice Address - Phone:440-250-1270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-05673225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist