Provider Demographics
NPI:1487428843
Name:DOUGHARTY, KIMBERLY PINE (LPAT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:PINE
Last Name:DOUGHARTY
Suffix:
Gender:F
Credentials:LPAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 VELARDE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-5126
Mailing Address - Country:US
Mailing Address - Phone:253-720-4871
Mailing Address - Fax:
Practice Address - Street 1:4730 BECKNER RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-3691
Practice Address - Country:US
Practice Address - Phone:505-989-4500
Practice Address - Fax:505-443-8313
Is Sole Proprietor?:No
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB20230922221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist