Provider Demographics
NPI:1962527028
Name:DOHERTY, MAUREEN HELEN (PTA)
Entity type:Individual
Prefix:MISS
First Name:MAUREEN
Middle Name:HELEN
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 COTTAGE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-2408
Mailing Address - Country:US
Mailing Address - Phone:507-236-0973
Mailing Address - Fax:
Practice Address - Street 1:1646 5TH AVE N
Practice Address - Street 2:
Practice Address - City:ESTHERVILLE
Practice Address - State:IA
Practice Address - Zip Code:51334-1760
Practice Address - Country:US
Practice Address - Phone:712-362-3522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00823225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant