Provider Demographics
NPI:1518905850
Name:DAUGHERTY, SUSAN MARIE (MSPT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:WEHRLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY
Mailing Address - Street 2:STE 300
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4915
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:631 N CAMPBELL STATION RD
Practice Address - Street 2:SUITE 1600
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-1628
Practice Address - Country:US
Practice Address - Phone:865-777-0367
Practice Address - Fax:865-777-0562
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT6921225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3156797OtherBCBST - GROUP NUMBER
TN0446652Medicaid
TN5441711Medicaid
TN446652Medicare ID - Type UnspecifiedGROUP NUMBER
TN0446652Medicaid