Basic Information
| Provider Information | |||||||||
| NPI: | 1811328867 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 ENTERPRISE RD APT 112 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895121677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306138246 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 W MOANA LANE, SUITE 2 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753372394 | ||||||||
| FaxNumber: | 7753379570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2013 | ||||||||
| LastUpdateDate: | 12/02/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.