Provider Demographics
NPI:1881945624
Name:DOUGHERTY, LORETTA JUNE
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:JUNE
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 1:4400 N LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-5104
Mailing Address - Country:US
Mailing Address - Phone:580-323-9773
Mailing Address - Fax:
Practice Address - Street 1:80 N 31ST ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-9116
Practice Address - Country:US
Practice Address - Phone:580-323-9773
Practice Address - Fax:580-323-0828
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator