Provider Demographics
NPI:1720771215
Name:DAUGHERTY, CHRISTOPHER JOHN
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JOHN
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 SHADY LANE DR STE D
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857-2710
Mailing Address - Country:US
Mailing Address - Phone:567-743-7199
Mailing Address - Fax:
Practice Address - Street 1:130 SHADY LANE DR STE D
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-2710
Practice Address - Country:US
Practice Address - Phone:567-743-7199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist