Provider Demographics
NPI:1164996427
Name:DAUGHERTY, BARET (PT)
Entity Type:Individual
Prefix:MR
First Name:BARET
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MOUNTAIN CREEK DR SE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-2146
Mailing Address - Country:US
Mailing Address - Phone:239-822-7947
Mailing Address - Fax:
Practice Address - Street 1:660 JOLLY RD NW
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-8633
Practice Address - Country:US
Practice Address - Phone:239-822-7947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT003494225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist