Provider Demographics
NPI:1932259678
Name:DAUGHERTY, LYNN B (PH D)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:B
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W 1ST ST
Mailing Address - Street 2:SUITE 323
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-4668
Mailing Address - Country:US
Mailing Address - Phone:505-623-1943
Mailing Address - Fax:
Practice Address - Street 1:200 W 1ST ST
Practice Address - Street 2:SUITE 323
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-4668
Practice Address - Country:US
Practice Address - Phone:505-623-1943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM237103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist