Provider Demographics
NPI:1043579667
Name:DAUGHERITY, MARK S (MPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:DAUGHERITY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E 2ND ST
Mailing Address - Street 2:SUITE 14
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2582
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 E 2ND ST
Practice Address - Street 2:SUITE 14
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2582
Practice Address - Country:US
Practice Address - Phone:307-337-1624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-0500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist