Provider Demographics
NPI:1588422596
Name:DAUGHERTY, KEITH WAYNE JR (LMSW)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:WAYNE
Last Name:DAUGHERTY
Suffix:JR
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-3641
Mailing Address - Country:US
Mailing Address - Phone:240-440-0226
Mailing Address - Fax:
Practice Address - Street 1:700 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-3641
Practice Address - Country:US
Practice Address - Phone:240-440-0226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD29740104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker