Provider Demographics
NPI:1962659185
Name:DAUGHERTY, MIKYTA DANIC (PHD)
Entity Type:Individual
Prefix:DR
First Name:MIKYTA
Middle Name:DANIC
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 DRIFTWOOD TER
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-4477
Mailing Address - Country:US
Mailing Address - Phone:404-590-8986
Mailing Address - Fax:
Practice Address - Street 1:1790 CENTURY BLVD NE
Practice Address - Street 2:SUITE B
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3322
Practice Address - Country:US
Practice Address - Phone:404-590-8986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003362103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003108634AMedicaid