Provider Demographics
NPI:1598362535
Name:DAUGHENBAUGH, ROBERT WILLIAM JR (LISAC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILLIAM
Last Name:DAUGHENBAUGH
Suffix:JR
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3914 E CORTEZ ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-2122
Mailing Address - Country:US
Mailing Address - Phone:859-319-7030
Mailing Address - Fax:602-252-0830
Practice Address - Street 1:3420 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3345
Practice Address - Country:US
Practice Address - Phone:602-730-5206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ155280101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ155280OtherLICENSED INDEPENDENT SUBSTANCE ABUSE COUNSELOR