Healthcare Provider Details

I. General information

NPI: 1497776223
Provider Name (Legal Business Name): MARGARET ELLEN DOHERTY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 BERDAN AVE WAYNE HILLS HIGH SCHOOL
WAYNE NJ
07470-3240
US

IV. Provider business mailing address

6 FERNDALE RD
WAYNE NJ
07470-7407
US

V. Phone/Fax

Practice location:
  • Phone: 973-633-3194
  • Fax: 973-633-3114
Mailing address:
  • Phone: 973-694-2189
  • Fax: 973-633-3114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00025700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: