Provider Demographics
NPI:1417580374
Name:DAUGHERTY, THERESA MARIE
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
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 1:430 FORRESTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST JEFFERSON
Mailing Address - State:OH
Mailing Address - Zip Code:43162-9552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:430 FORRESTWOOD AVE
Practice Address - Street 2:
Practice Address - City:WEST JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:43162-9552
Practice Address - Country:US
Practice Address - Phone:614-354-7270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider