Provider Demographics
NPI:1528303666
Name:DOUGHERTY, MICHELLE
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
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 1:525 ROUTE 73 N STE 104
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3422
Mailing Address - Country:US
Mailing Address - Phone:609-575-2661
Mailing Address - Fax:
Practice Address - Street 1:525 ROUTE 73 NORTH
Practice Address - Street 2:SUITE 104
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3422
Practice Address - Country:US
Practice Address - Phone:609-575-2661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-30
Last Update Date:2020-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00540700235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist