Provider Demographics
NPI:1104279371
Name:CLOUGHERTY, JOHN (MED,LAT, ATC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CLOUGHERTY
Suffix:
Gender:M
Credentials:MED,LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12038 STATE HIGHWAY 205
Mailing Address - Street 2:
Mailing Address - City:LAVON
Mailing Address - State:TX
Mailing Address - Zip Code:75166-1846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12038 STATE HIGHWAY 205
Practice Address - Street 2:
Practice Address - City:LAVON
Practice Address - State:TX
Practice Address - Zip Code:75166-1846
Practice Address - Country:US
Practice Address - Phone:972-722-4875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT06332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer