Provider Demographics
NPI:1295091668
Name:DAUGHERTY, BRIAN EVAN (LCSW)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:EVAN
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 TILLAMOOK DR
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-4934
Mailing Address - Country:US
Mailing Address - Phone:919-946-2987
Mailing Address - Fax:
Practice Address - Street 1:214 TILLAMOOK DR
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-4934
Practice Address - Country:US
Practice Address - Phone:919-946-2987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0070411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical