Provider Demographics
NPI:1336794999
Name:DOUGHTY, KATHERINE ANNE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANNE
Last Name:DOUGHTY
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 1:95 EASTERN AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-4582
Mailing Address - Country:US
Mailing Address - Phone:855-924-5378
Mailing Address - Fax:
Practice Address - Street 1:95 EASTERN AVE STE 8
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-4582
Practice Address - Country:US
Practice Address - Phone:855-924-5378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA3898103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid