Provider Demographics
NPI:1407281926
Name:DAUGHERTY, MARY COURTENAY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:COURTENAY
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 1:4451 ROSE DALE CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-6324
Mailing Address - Country:US
Mailing Address - Phone:502-836-7140
Mailing Address - Fax:
Practice Address - Street 1:161 BURT RD STE 4
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2410
Practice Address - Country:US
Practice Address - Phone:859-276-0335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225CX0006XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorOrientation and Mobility Training Provider