Healthcare Provider Details

I. General information

NPI: 1235753385
Provider Name (Legal Business Name): KIMBERLY SUE DOUGHERTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 CENTRAL AVE
ST PETERSBURG FL
33711-1239
US

IV. Provider business mailing address

1848 SE 1ST AVE
FORT LAUDERDALE FL
33316-2875
US

V. Phone/Fax

Practice location:
  • Phone: 727-327-7656
  • Fax:
Mailing address:
  • Phone: 954-366-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: