Provider Demographics
NPI:1730200635
Name:DOUGHERTY, KEVIN RICHARD (PHD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:RICHARD
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-1451
Mailing Address - Country:US
Mailing Address - Phone:609-926-9668
Mailing Address - Fax:609-926-4153
Practice Address - Street 1:1910 WABASH AVE
Practice Address - Street 2:
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1451
Practice Address - Country:US
Practice Address - Phone:609-926-9668
Practice Address - Fax:609-926-4153
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00327200103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist