Provider Demographics
NPI:1598043218
Name:DAUGHERTY, MARTY LEES (LCSW)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:LEES
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4860 ROBB ST STE 201
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2162
Mailing Address - Country:US
Mailing Address - Phone:303-278-7418
Mailing Address - Fax:888-341-5050
Practice Address - Street 1:14555 E HAMPDEN AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-5041
Practice Address - Country:US
Practice Address - Phone:303-278-7418
Practice Address - Fax:888-341-5050
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO989043101YM0800X
COCSW.009890431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health