Provider Demographics
NPI:1154834364
Name:DAUGHERTY, KYLE RICHARD (DPT)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:RICHARD
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 ATRIUM WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6301
Mailing Address - Country:US
Mailing Address - Phone:803-359-0505
Mailing Address - Fax:
Practice Address - Street 1:229 SALUDA SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-6667
Practice Address - Country:US
Practice Address - Phone:803-359-0505
Practice Address - Fax:803-359-2206
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26779225100000X
SC10527225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist