Provider Demographics
NPI:1265791446
Name:DOUGHERTY, KIMBERLY A (OT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:A
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 MAIN ST
Mailing Address - Street 2:#400
Mailing Address - City:HARLEYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19438-1671
Mailing Address - Country:US
Mailing Address - Phone:215-366-5978
Mailing Address - Fax:215-366-5956
Practice Address - Street 1:1120 YORK RD
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1334
Practice Address - Country:US
Practice Address - Phone:215-366-5978
Practice Address - Fax:215-366-5956
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC004544L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist