Provider Demographics
NPI:1669752499
Name:DOHERTY, RENEE MARIE (MPT)
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:MARIE
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MS
Other - First Name:RENEE
Other - Middle Name:MARIE
Other - Last Name:STRUSOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4615 MUGGLETON RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-4101
Mailing Address - Country:US
Mailing Address - Phone:302-633-0261
Mailing Address - Fax:
Practice Address - Street 1:750 SHIPYARD DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-5157
Practice Address - Country:US
Practice Address - Phone:302-658-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10001052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist