Provider Demographics
NPI:1871280040
Name:DAUGHERTY, CHARLES ROBERT (CDCA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROBERT
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MONTGOMERY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2600
Mailing Address - Country:US
Mailing Address - Phone:833-510-4357
Mailing Address - Fax:
Practice Address - Street 1:1012 E PERKINS AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5070
Practice Address - Country:US
Practice Address - Phone:833-510-4357
Practice Address - Fax:567-243-2097
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.183679101YA0400X
OHCDCA.187659101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)