Provider Demographics
NPI:1881711026
Name:DOUGHERTY, JOHN
Entity type:Individual
Prefix:PROF
First Name:JOHN
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W FIRETOWER RD STE D
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-8408
Mailing Address - Country:US
Mailing Address - Phone:252-830-3300
Mailing Address - Fax:252-830-3322
Practice Address - Street 1:108 W FIRETOWER RD STE D
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-8408
Practice Address - Country:US
Practice Address - Phone:252-830-3300
Practice Address - Fax:252-830-3322
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC411106H00000X
NC1094103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist