Provider Demographics
NPI:1447951298
Name:DOUGHERTY, RONDA JO
Entity type:Individual
Prefix:
First Name:RONDA
Middle Name:JO
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-3141
Mailing Address - Country:US
Mailing Address - Phone:530-351-8658
Mailing Address - Fax:
Practice Address - Street 1:118 BELLE MILL RD
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-2850
Practice Address - Country:US
Practice Address - Phone:530-840-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 175T00000X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health