Provider Demographics
NPI:1114206356
Name:DAUGHERTY MEADOWS, STACI (LPCC)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:DAUGHERTY MEADOWS
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:
Other - Last Name:DAUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:130 SOUTHERN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-3223
Mailing Address - Country:US
Mailing Address - Phone:606-679-4782
Mailing Address - Fax:
Practice Address - Street 1:90 MEDICAL LN
Practice Address - Street 2:
Practice Address - City:WHITLEY CITY
Practice Address - State:KY
Practice Address - Zip Code:42653-4216
Practice Address - Country:US
Practice Address - Phone:606-376-2466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY103380101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100285790Medicaid