Healthcare Provider Details

I. General information

NPI: 1790769677
Provider Name (Legal Business Name): KATHERINE JOANNE DAUGHERTY LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2005
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4040 W 86TH ST
INDIANAPOLIS IN
46268-7800
US

IV. Provider business mailing address

1517 E 81ST ST
INDIANAPOLIS IN
46240-2715
US

V. Phone/Fax

Practice location:
  • Phone: 317-876-3600
  • Fax:
Mailing address:
  • Phone: 317-253-7820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001542A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: