Provider Demographics
NPI:1295281202
Name:DOUGHERTY, LAURA SEMON (PT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:SEMON
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ELIZABETH
Other - Last Name:SEMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:334 PATRIOT DR
Mailing Address - Street 2:
Mailing Address - City:LOGAN TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08085-4254
Mailing Address - Country:US
Mailing Address - Phone:601-209-6454
Mailing Address - Fax:
Practice Address - Street 1:1600 ROCKLAND RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3607
Practice Address - Country:US
Practice Address - Phone:302-298-7018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0002369174400000X
PAPT013595L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist