Provider Demographics
NPI:1194132993
Name:DAUGHERTY, PHILIP MIDDLE (LMT/LMP)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:MIDDLE
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:LMT/LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 CAMPBELL WAY
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3380
Mailing Address - Country:US
Mailing Address - Phone:360-710-3190
Mailing Address - Fax:
Practice Address - Street 1:10513 SILVERDALE WAY NW STE 102
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9499
Practice Address - Country:US
Practice Address - Phone:360-698-4411
Practice Address - Fax:360-698-6953
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60267132225700000X, 173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist