Provider Demographics
NPI:1750544177
Name:DOUGHERTY, LAURA JEEP (MS CCC SLP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JEEP
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6809 ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-2213
Mailing Address - Country:US
Mailing Address - Phone:314-402-6213
Mailing Address - Fax:
Practice Address - Street 1:312 SOLLEY DR
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-5248
Practice Address - Country:US
Practice Address - Phone:636-391-0666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE188235Z00000X
MO2009030845235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist