Provider Demographics
NPI:1811772098
Name:DAUGHERTY, KYLEIGH GRACE (M ED CCC-SLP)
Entity type:Individual
Prefix:
First Name:KYLEIGH
Middle Name:GRACE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:M ED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5516 ROCKFERN DR
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3867
Mailing Address - Country:US
Mailing Address - Phone:229-305-7773
Mailing Address - Fax:
Practice Address - Street 1:311 COOPER RD
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4976
Practice Address - Country:US
Practice Address - Phone:678-205-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP012656235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist