Basic Information
| Provider Information | |||||||||
| NPI: | 1992221550 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11074 ALDINA DR | ||||||||
| Address2: | |||||||||
| City: | CONNEAUT LAKE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163162718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143822718 | ||||||||
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| Practice Location | |||||||||
| Address1: | 339 E MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447202593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304988200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2017 | ||||||||
| LastUpdateDate: | 08/16/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OP001416L | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.