Healthcare Provider Details

I. General information

NPI: 1093045452
Provider Name (Legal Business Name): TIMOTHY DOUGHERTY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2010
Last Update Date: 01/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1437 S BELCHER RD
CLEARWATER FL
33764-2829
US

IV. Provider business mailing address

1437 S BELCHER RD
CLEARWATER FL
33764-2829
US

V. Phone/Fax

Practice location:
  • Phone: 727-524-4464
  • Fax: 727-524-4491
Mailing address:
  • Phone: 727-524-4464
  • Fax: 727-524-4491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: