Provider Demographics
NPI:1447958772
Name:OBRIEN DAUGHERTY, HEATHER MICHELLE (LMT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MICHELLE
Last Name:OBRIEN DAUGHERTY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 711
Mailing Address - Street 2:
Mailing Address - City:LANGLEY
Mailing Address - State:OK
Mailing Address - Zip Code:74350-0711
Mailing Address - Country:US
Mailing Address - Phone:417-669-4637
Mailing Address - Fax:
Practice Address - Street 1:337 N JOHNSON ST.
Practice Address - Street 2:
Practice Address - City:DISNEY
Practice Address - State:OK
Practice Address - Zip Code:74340
Practice Address - Country:US
Practice Address - Phone:417-669-4637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR9235225700000X
OK192453225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist