Provider Demographics
NPI:1649431339
Name:DOHERTY, JULIETTE LYN (OTR/L)
Entity type:Individual
Prefix:
First Name:JULIETTE
Middle Name:LYN
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 BOYLE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-1955
Mailing Address - Country:US
Mailing Address - Phone:631-929-3306
Mailing Address - Fax:
Practice Address - Street 1:239 BOYLE RD STE 3
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-1955
Practice Address - Country:US
Practice Address - Phone:631-929-3306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012457-1225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics