Provider Demographics
NPI:1962286443
Name:DAUGHERTY, SAMANTHA (MA, CF-SLP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:MA, CF-SLP
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:DAUGHERTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, CF-SLP
Mailing Address - Street 1:163 FAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4427
Mailing Address - Country:US
Mailing Address - Phone:804-824-7609
Mailing Address - Fax:
Practice Address - Street 1:5604 VIRGINIA BEACH BLVD BLDG A
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5631
Practice Address - Country:US
Practice Address - Phone:747-455-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204001261235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist