Provider Demographics
NPI:1780200212
Name:DAUGHERTY, NATE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NATE
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 387
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-0387
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2203 GRAVES MILL RD STE A
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-4297
Practice Address - Country:US
Practice Address - Phone:434-851-0091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-20
Last Update Date:2020-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305213637225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist