Healthcare Provider Details

I. General information

NPI: 1336180249
Provider Name (Legal Business Name): KEVIN PATRICK DOHERTY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 05/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14825 N OUTER FORTY ROAD SUITE 300
CHESTERFIELD MO
63005-0002
US

IV. Provider business mailing address

13537 BARRETT PARKWAY DRIVE SUITE 105
BALLWIN MO
63021-5866
US

V. Phone/Fax

Practice location:
  • Phone: 636-812-1211
  • Fax: 636-812-0159
Mailing address:
  • Phone: 314-821-9126
  • Fax: 314-821-9142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number2006009447
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: