Healthcare Provider Details

I. General information

NPI: 1386343036
Provider Name (Legal Business Name): WILLIAM MATTHEW DAUGHERTY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2023
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12395 MORRIS RD
ALPHARETTA GA
30005-4000
US

IV. Provider business mailing address

6505 SHILOH RD STE 100
ALPHARETTA GA
30005-1645
US

V. Phone/Fax

Practice location:
  • Phone: 678-648-7644
  • Fax:
Mailing address:
  • Phone: 678-648-7644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-268677
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: