Provider Demographics
NPI:1205309424
Name:DOUGHERTY, MEGAN (OTR/L)
Entity type:Individual
Prefix:
First Name:MEGAN
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 1:16257 BERRY VIEW CT
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2078
Mailing Address - Country:US
Mailing Address - Phone:636-458-4126
Mailing Address - Fax:
Practice Address - Street 1:10000 W 75TH ST STE 250
Practice Address - Street 2:
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204-2218
Practice Address - Country:US
Practice Address - Phone:636-458-4126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018035294225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist