Provider Demographics
NPI:1891910055
Name:DAUGHERTY, LAURA L
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:L
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 1:1312 BETTY JANE ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320-1333
Mailing Address - Country:US
Mailing Address - Phone:270-274-8204
Mailing Address - Fax:
Practice Address - Street 1:1312 BETTY JANE ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320-1333
Practice Address - Country:US
Practice Address - Phone:270-274-8204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY019292255R0406X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255R0406XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistRehabilitation, Blind
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY01929OtherSERVICE PROVIDER