Provider Demographics
NPI:1457404774
Name:DOHERTY, THOMAS JOSEPH III (PSYD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOSEPH
Last Name:DOHERTY
Suffix:III
Gender:M
Credentials:PSYD
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 3174
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3174
Mailing Address - Country:US
Mailing Address - Phone:503-288-1213
Mailing Address - Fax:503-296-5393
Practice Address - Street 1:5257 NE MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3282
Practice Address - Country:US
Practice Address - Phone:503-288-1213
Practice Address - Fax:503-296-5393
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1628103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist