Provider Demographics
NPI:1104156157
Name:DAUGHERTY-SHRIVASTAVA, BRENDA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:DAUGHERTY-SHRIVASTAVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SHENANGO AVE
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:PA
Mailing Address - Zip Code:16146-1503
Mailing Address - Country:US
Mailing Address - Phone:814-223-9914
Mailing Address - Fax:814-223-9917
Practice Address - Street 1:30 PINNACLE DR
Practice Address - Street 2:
Practice Address - City:CLARION
Practice Address - State:PA
Practice Address - Zip Code:16214-3800
Practice Address - Country:US
Practice Address - Phone:814-223-9914
Practice Address - Fax:814-223-9917
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC000561101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPC000561OtherLICENSED PROFESSIONAL COUNSELOR