Provider Demographics
NPI:1285058834
Name:DAUGHERTY, LEZLIE
Entity type:Individual
Prefix:
First Name:LEZLIE
Middle Name:
Last Name:DAUGHERTY
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 1:17087 S HWY 51A
Mailing Address - Street 2:
Mailing Address - City:WATONGA
Mailing Address - State:OK
Mailing Address - Zip Code:73772
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17087 S HIGHWAY 51A
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-5054
Practice Address - Country:US
Practice Address - Phone:580-791-3084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health