Provider Demographics
NPI:1134168099
Name:DAUGHERTY, TIMOTHY KENNETH (PHD, ABPP)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:KENNETH
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1998 ALDERSGATE RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1355
Mailing Address - Country:US
Mailing Address - Phone:803-322-5695
Mailing Address - Fax:
Practice Address - Street 1:1601 EBENEZER RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1808
Practice Address - Country:US
Practice Address - Phone:803-322-5695
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC556103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0208Medicaid