Provider Demographics
NPI:1659143626
Name:DAUGHERTY, JUDITH
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:
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 1:36851 W MONDRAGONE LN
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-4949
Mailing Address - Country:US
Mailing Address - Phone:602-341-1141
Mailing Address - Fax:
Practice Address - Street 1:36851 W MONDRAGONE LN
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-4949
Practice Address - Country:US
Practice Address - Phone:602-341-1141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA14691235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist