Basic Information
| Provider Information | |||||||||
| NPI: | 1760622286 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | MARSHA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MS, PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2033 EXCELSIOR DR SE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985013775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604647459 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2430 N 13TH ST | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985841213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604261651 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2009 | ||||||||
| LastUpdateDate: | 02/23/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251G0304X | PT00010578 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics |
ID Information
| ID | Type | State | Issuer | Description | PT00010578 | 01 | WA | DEPARTMENT OF HEALTH | OTHER |