Provider Demographics
NPI:1902922206
Name:DAUGHERTY, LINDA DIANE (MFT)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:DIANE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 ELM RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-7344
Mailing Address - Country:US
Mailing Address - Phone:760-734-3889
Mailing Address - Fax:
Practice Address - Street 1:120 MATA WAY STE 101
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2936
Practice Address - Country:US
Practice Address - Phone:760-510-4737
Practice Address - Fax:760-510-4738
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 30267106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist