Provider Demographics
NPI:1063167062
Name:DOUGHERTY, MARIKO LEIGH (MS, CCC- SLP)
Entity type:Individual
Prefix:
First Name:MARIKO
Middle Name:LEIGH
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MS, CCC- SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 NORMAN DR
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-4415
Mailing Address - Country:US
Mailing Address - Phone:214-457-7359
Mailing Address - Fax:
Practice Address - Street 1:508 NORMAN DR
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-4415
Practice Address - Country:US
Practice Address - Phone:214-457-7359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR201743235Z00000X
TX111460235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty