Basic Information
| Provider Information | |||||||||
| NPI: | 1487708350 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | BSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 227 E FOURTH ST | ||||||||
| Address2: | |||||||||
| City: | MEDIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190633008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105665197 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2600 W 9TH ST | ||||||||
| Address2: | 4TH FLR | ||||||||
| City: | CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190132040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104977249 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.