Provider Demographics
NPI:1578345203
Name:DAUGHERTY, SANDRA (PT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2980 RIPPLE PL APT 202
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-2965
Mailing Address - Country:US
Mailing Address - Phone:310-804-6266
Mailing Address - Fax:
Practice Address - Street 1:8250 WOODMAN AVE BLDG 2
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-5427
Practice Address - Country:US
Practice Address - Phone:818-815-6049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist