Provider Demographics
NPI:1720043938
Name:DAUGHERTY, ROBERT LEE (MFT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEE
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 CREST ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1952
Mailing Address - Country:US
Mailing Address - Phone:262-767-0440
Mailing Address - Fax:262-767-0777
Practice Address - Street 1:201 CREST ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1952
Practice Address - Country:US
Practice Address - Phone:262-767-0440
Practice Address - Fax:262-767-0777
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI234124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist