Basic Information
| Provider Information | |||||||||
| NPI: | 1578689790 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | JORDAN | ||||||||
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| Credential: | PT, MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1940 BONITA DRIVE | ||||||||
| Address2: | |||||||||
| City: | APTOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316841804 | ||||||||
| FaxNumber: | 8316841826 | ||||||||
| Practice Location | |||||||||
| Address1: | 638 BRANDYWINE PKWY | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193804278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104363600 | ||||||||
| FaxNumber: | 6104363606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 12/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT017564 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1018303320001 | 05 | PA | MEDICAID |