=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689245615
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN O'NEAL DOHERTY PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2021
-----------------------------------------------------
Last Update Date | 09/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 676 N SAINT CLAIR ST STE 950
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-694-7337
-----------------------------------------------------
Fax | 312-695-0156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 676 N SAINT CLAIR ST STE 950
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-694-7337
-----------------------------------------------------
Fax | 312-695-0156
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070.025995
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------