Provider Demographics
NPI:1407095045
Name:DAUGHERTY, ROBERTA ANNE (LAC, MSTOM, BA)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:ANNE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:LAC, MSTOM, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9820 WILLOW CREEK RD
Mailing Address - Street 2:SUITE #485
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-1112
Mailing Address - Country:US
Mailing Address - Phone:858-689-2279
Mailing Address - Fax:858-689-2274
Practice Address - Street 1:9820 WILLOW CREEK RD
Practice Address - Street 2:SUITE #485
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1112
Practice Address - Country:US
Practice Address - Phone:858-689-2279
Practice Address - Fax:858-689-2274
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12060171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist