Provider Demographics
NPI:1881745453
Name:DAUGHERTY, DOUGLAS A (PSYD,HSPP)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:A
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:PSYD,HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5230 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-5778
Mailing Address - Country:US
Mailing Address - Phone:765-674-2208
Mailing Address - Fax:765-674-3273
Practice Address - Street 1:5230 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-5778
Practice Address - Country:US
Practice Address - Phone:765-674-2208
Practice Address - Fax:765-674-3273
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041195A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN160445000OtherMAGELLAN
IN200858320Medicaid
IN000000249176OtherANTHEMBCBS
IN7580201OtherAETNA
IN200858320Medicaid
INDAUG-1977OtherCOMPCARE