MEDICARE: SUSAN DOUGHERTY

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	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1528569894
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN DOUGHERTY

Provider Business Mailing Address
First Line	:	4019 CAMAS CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-2523
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4019 CAMAS CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-2523
Country	:	US
Telephone Number	:	623-850-0733
Fax Number	:

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

Provider Enumeration Date	:	02/22/2018
Last Update Date	:	02/22/2018

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Directions to “ SUSAN DOUGHERTY ” Practice Location

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