Provider Demographics
NPI:1770624918
Name:DAUGHTRY, SEAN P (LICSW)
Entity type:Individual
Prefix:MR
First Name:SEAN
Middle Name:P
Last Name:DAUGHTRY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE SALEM GREEN
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970
Mailing Address - Country:US
Mailing Address - Phone:978-535-6043
Mailing Address - Fax:
Practice Address - Street 1:ONE SALEM GREEN
Practice Address - Street 2:SUITE 400
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970
Practice Address - Country:US
Practice Address - Phone:978-535-6043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1106321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110095822AMedicaid
MA110095822AMedicaid