Provider Demographics
NPI:1194092734
Name:DAUGHERTY, CHRISTINE MARIE (RN)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-3036
Mailing Address - Country:US
Mailing Address - Phone:269-926-0015
Mailing Address - Fax:369-926-0015
Practice Address - Street 1:1022 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-3036
Practice Address - Country:US
Practice Address - Phone:269-926-0015
Practice Address - Fax:269-926-0015
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704209681101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)