Provider Demographics
NPI:1104078666
Name:DAUGHTERY, GLORIA HARRIS (LPC)
Entity type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:HARRIS
Last Name:DAUGHTERY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:
Other - Last Name:DAUGHTERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:318 S WELBORN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-3127
Mailing Address - Country:US
Mailing Address - Phone:912-332-5145
Mailing Address - Fax:912-332-5143
Practice Address - Street 1:318 S WELBORN ST
Practice Address - Street 2:SUITE C
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-3127
Practice Address - Country:US
Practice Address - Phone:912-332-5145
Practice Address - Fax:912-332-5143
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005336101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA603509452BMedicaid