Healthcare Provider Details

I. General information

NPI: 1790111078
Provider Name (Legal Business Name): PAMELA THYRA DOHERTY M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4744 70TH ST UNIT 5
LA MESA CA
91942-4552
US

IV. Provider business mailing address

4744 70TH ST UNIT 5
LA MESA CA
91942-4552
US

V. Phone/Fax

Practice location:
  • Phone: 619-303-0110
  • Fax:
Mailing address:
  • Phone: 619-303-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: