Provider Demographics
NPI:1790995876
Name:DAUGHERTY, KRISTEN DAWN (LISW)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:DAWN
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 N WHITE SANDS BLVD
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-6140
Mailing Address - Country:US
Mailing Address - Phone:915-351-4680
Mailing Address - Fax:915-351-3643
Practice Address - Street 1:616 N VIRGINIA ST
Practice Address - Street 2:SUITE B
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-5310
Practice Address - Country:US
Practice Address - Phone:915-351-4680
Practice Address - Fax:915-351-3643
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX414971041C0700X
NMI-065741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical