Provider Demographics
NPI:1295753366
Name:DOUGHERTY, DENISE L (MA, CCC-SLP, MFT)
Entity type:Individual
Prefix:MS
First Name:DENISE
Middle Name:L
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MA, CCC-SLP, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1155
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-1155
Mailing Address - Country:US
Mailing Address - Phone:724-349-4978
Mailing Address - Fax:724-349-4990
Practice Address - Street 1:PO BOX 1155
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-1155
Practice Address - Country:US
Practice Address - Phone:724-349-4978
Practice Address - Fax:724-349-4990
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL004074L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013967300001Medicaid
PADO1753263OtherHIGHMARK BLUE SHIELD
202285795OtherTRICARE