Healthcare Provider Details

I. General information

NPI: 1356706121
Provider Name (Legal Business Name): MICHELE DOUGHERTY MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1768 BUSINESS CENTER DR STE 330
RESTON VA
20190-4882
US

IV. Provider business mailing address

10150 VILLAGE KNOLLS CT
OAKTON VA
22124-2728
US

V. Phone/Fax

Practice location:
  • Phone: 186-691-9324
  • Fax:
Mailing address:
  • Phone: 914-471-0176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0119008061
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: