Provider Demographics
NPI:1669141388
Name:DAUGHERTY, SAVANNA (APC)
Entity type:Individual
Prefix:
First Name:SAVANNA
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 MARGO TRL SE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-9424
Mailing Address - Country:US
Mailing Address - Phone:772-812-6450
Mailing Address - Fax:
Practice Address - Street 1:3732 CEDARCREST RD STE 104
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-2324
Practice Address - Country:US
Practice Address - Phone:678-941-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional