Provider Demographics
NPI:1376109975
Name:DAUGHERTY, SANTANA MARIE (LGPC)
Entity Type:Individual
Prefix:
First Name:SANTANA
Middle Name:MARIE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11301 DOGWOOD DR APT 21
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-7002
Mailing Address - Country:US
Mailing Address - Phone:240-469-8640
Mailing Address - Fax:
Practice Address - Street 1:2225 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5778
Practice Address - Country:US
Practice Address - Phone:410-812-3750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD39730101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health