Provider Demographics
NPI:1912262692
Name:DOUGHERTY, DEBRA ANN (MSW)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:ANN
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:DEBRA
Other - Middle Name:ANN
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BSW
Mailing Address - Street 1:6242 E BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-9730
Mailing Address - Country:US
Mailing Address - Phone:850-380-4797
Mailing Address - Fax:
Practice Address - Street 1:3686 US HIGHWAY 331 S
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-8463
Practice Address - Country:US
Practice Address - Phone:850-892-8035
Practice Address - Fax:850-892-8074
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker