Healthcare Provider Details

I. General information

NPI: 1033608781
Provider Name (Legal Business Name): PAIGE E DOUGHERTY PT, DPT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3004 N WATER ST STE C
DECATUR IL
62526-1960
US

IV. Provider business mailing address

PO BOX 220
WESTMONT IL
60559-0220
US

V. Phone/Fax

Practice location:
  • Phone: 217-233-0030
  • Fax: 217-233-0031
Mailing address:
  • Phone: 708-590-6663
  • Fax: 708-469-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070026601
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: