Healthcare Provider Details

I. General information

NPI: 1952430571
Provider Name (Legal Business Name): MELANIE MADISON DAUGHERTY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 8TH ST
CLARKSVILLE TN
37040-3093
US

IV. Provider business mailing address

918 S RIDGE TRL
CLARKSVILLE TN
37043-8275
US

V. Phone/Fax

Practice location:
  • Phone: 931-920-7330
  • Fax:
Mailing address:
  • Phone: 931-362-4964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4107
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: