MEDICARE: CHRISTINE E DOUGHERTY BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-16-24077

General Provider Information

NPI Number	:	1942711627
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE E DOUGHERTY BCBA

Provider Business Mailing Address
First Line	:	353 RIVERDALE DR
Second Line	:
City	:	KEYPORT
State	:	NJ
Zip	:	07735-5022
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 RAVEN LN
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-4968
Country	:	US
Telephone Number	:	732-730-0700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2017
Last Update Date	:	10/20/2017

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