Healthcare Provider Details

I. General information

NPI: 1407364342
Provider Name (Legal Business Name): CAROLINE DAUGHERTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2076 S INDEPENDENCE BLVD
VIRGINIA BEACH VA
23453-4779
US

IV. Provider business mailing address

3101 MAGIC HOLLOW BLVD, VIRGINIA BEACH, VA 23453
VIRGINIA BEACH VA
23453-1177
US

V. Phone/Fax

Practice location:
  • Phone: 757-622-7272
  • Fax:
Mailing address:
  • Phone: 757-639-2218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: