Provider Demographics
NPI:1134692494
Name:DAUGHERTY, HEATHER M
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4662 JADE ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-3134
Mailing Address - Country:US
Mailing Address - Phone:503-409-1100
Mailing Address - Fax:
Practice Address - Street 1:4662 JADE ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305
Practice Address - Country:US
Practice Address - Phone:971-453-3430
Practice Address - Fax:503-400-3058
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor