Provider Demographics
NPI:1144854480
Name:DAUGHERTY, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
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 1:4604 US HIGHWAY 60 W
Mailing Address - Street 2:
Mailing Address - City:MORGANFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42437-6515
Mailing Address - Country:US
Mailing Address - Phone:270-389-5170
Mailing Address - Fax:270-389-5174
Practice Address - Street 1:212 E MCELROY ST
Practice Address - Street 2:
Practice Address - City:MORGANFIELD
Practice Address - State:KY
Practice Address - Zip Code:42437-1583
Practice Address - Country:US
Practice Address - Phone:270-621-5108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY131148225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist