Provider Demographics
NPI:1750678694
Name:DAUGHERTY, AMANDA (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:MARCUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:940 LASLEY DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1480
Mailing Address - Country:US
Mailing Address - Phone:888-714-1927
Mailing Address - Fax:317-272-1713
Practice Address - Street 1:940 LASLEY DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-1480
Practice Address - Country:US
Practice Address - Phone:888-714-1927
Practice Address - Fax:317-272-1713
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006228A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical