Provider Demographics
NPI:1497177505
Name:DAUGHERTY, TIFFANY DAWN
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DAWN
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 1:165 WINNGATE RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-5392
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2423
Practice Address - Country:US
Practice Address - Phone:270-594-1199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY292956106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist