Provider Demographics
NPI:1205808193
Name:DAUGHERTY, DEBORAH LYNN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:LYNN
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3108 GLENVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46012
Mailing Address - Country:US
Mailing Address - Phone:765-378-6730
Mailing Address - Fax:
Practice Address - Street 1:3645 BRIARWOOD LANE
Practice Address - Street 2:BRIARWOOD CLINIC
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304
Practice Address - Country:US
Practice Address - Phone:765-289-5520
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000325104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000210926OtherANTHEM
IN197560AMedicare ID - Type Unspecified