Provider Demographics
NPI:1265581482
Name:DAUGHERTY, KELLY LYNN (LCSW-R)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SARATOGA VILLAGE BLVD STE 21
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3703
Mailing Address - Country:US
Mailing Address - Phone:518-219-8625
Mailing Address - Fax:
Practice Address - Street 1:100 SARATOGA VILLAGE BLVD STE 21
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-3703
Practice Address - Country:US
Practice Address - Phone:518-219-8625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0053971041C0700X
NYR0774531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106466Medicaid