Provider Demographics
NPI:1144906132
Name:DOUGHERTY, ELIZABETH ANN (OTD, OTR)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:OTD, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 MEADOW PLACE DR APT 4210
Mailing Address - Street 2:
Mailing Address - City:WILLOW PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76087-6756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10640 N RIVERSIDE DR STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-9506
Practice Address - Country:US
Practice Address - Phone:817-431-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123644225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123644OtherOCCUPATIONAL THERAPY