Healthcare Provider Details

I. General information

NPI: 1447958772
Provider Name (Legal Business Name): HEATHER MICHELLE OBRIEN DAUGHERTY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 02/16/2023
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

337 N JOHNSON ST.
DISNEY OK
74340
US

IV. Provider business mailing address

PO BOX 711
LANGLEY OK
74350-0711
US

V. Phone/Fax

Practice location:
  • Phone: 417-669-4637
  • Fax:
Mailing address:
  • Phone: 417-669-4637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number9235
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number192453
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: