Healthcare Provider Details

I. General information

NPI: 1285641977
Provider Name (Legal Business Name): JAMES PATRICK DOHERTY PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 RAYBROOK ST STE 303
GRAND RAPIDS MI
49546-7717
US

IV. Provider business mailing address

2020 RAYBROOK ST STE 303
GRAND RAPIDS MI
49546-7717
US

V. Phone/Fax

Practice location:
  • Phone: 616-464-1747
  • Fax: 616-464-1748
Mailing address:
  • Phone: 616-464-1747
  • Fax: 616-464-1748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301011612
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: