Provider Demographics
NPI:1215070198
Name:DOUGHERTY, MARY ELLEN (PT)
Entity type:Individual
Prefix:MS
First Name:MARY ELLEN
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 THURLOW DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205-2826
Mailing Address - Country:US
Mailing Address - Phone:315-492-6720
Mailing Address - Fax:
Practice Address - Street 1:813 FAY RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-3009
Practice Address - Country:US
Practice Address - Phone:315-703-0762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005030-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist