Provider Demographics
NPI:1770083982
Name:DAUGHERTY, ALTON KEITH (LCDC III)
Entity type:Individual
Prefix:
First Name:ALTON
Middle Name:KEITH
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 VERNON DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-4752
Mailing Address - Country:US
Mailing Address - Phone:937-416-9030
Mailing Address - Fax:
Practice Address - Street 1:200 DARUMA PKWY
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-7909
Practice Address - Country:US
Practice Address - Phone:937-963-5522
Practice Address - Fax:937-496-5216
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161525101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)