Provider Demographics
NPI:1538860770
Name:DAUGHERTY, LISA DEANNE (CADAC II)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DEANNE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:CADAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8367 TAGUE RD
Mailing Address - Street 2:
Mailing Address - City:VEVAY
Mailing Address - State:IN
Mailing Address - Zip Code:47043-2818
Mailing Address - Country:US
Mailing Address - Phone:513-200-9723
Mailing Address - Fax:
Practice Address - Street 1:8367 TAGUE RD
Practice Address - Street 2:
Practice Address - City:VEVAY
Practice Address - State:IN
Practice Address - Zip Code:47043-2818
Practice Address - Country:US
Practice Address - Phone:513-200-9723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INC2-51306101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)