Provider Demographics
NPI:1841475423
Name:DOUGHERTY, LINDA (CRC, QRP)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:CRC, QRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 SUN VLY
Mailing Address - Street 2:
Mailing Address - City:GLEN DALE
Mailing Address - State:WV
Mailing Address - Zip Code:26038-1222
Mailing Address - Country:US
Mailing Address - Phone:304-845-1836
Mailing Address - Fax:304-843-1783
Practice Address - Street 1:30 SUN VLY
Practice Address - Street 2:
Practice Address - City:GLEN DALE
Practice Address - State:WV
Practice Address - Zip Code:26038-1222
Practice Address - Country:US
Practice Address - Phone:304-845-1836
Practice Address - Fax:304-843-1783
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
00047827OtherCRC