MEDICARE: LISA MARIE DOUGHERTY PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT006185	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	52676665	OTHER	GA	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164538773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARIE DOUGHERTY PT, DPT

Provider Business Mailing Address
First Line	:	1200 CORPORATE DR STE 400
Second Line	:
City	:	HOOVER
State	:	AL
Zip	:	35242-5424
Country	:	US
Telephone Number	:	866-518-0283
Fax Number	:	423-238-3628

Provider Business Practice Location Address
First Line	:	660 LAKE JOY RD STE D
Second Line	:
City	:	KATHLEEN
State	:	GA
Zip	:	31047-2382
Country	:	US
Telephone Number	:	478-313-5385
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	02/22/2024

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