Provider Demographics
NPI:1669347795
Name:DAUGHERTY, HOLLY JO
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:JO
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 1:4707 COTTAGE WAY
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-5610
Mailing Address - Country:US
Mailing Address - Phone:916-380-8785
Mailing Address - Fax:
Practice Address - Street 1:7000 FRANKLIN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-1865
Practice Address - Country:US
Practice Address - Phone:916-919-3470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-08
Last Update Date:2025-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10291101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)