Healthcare Provider Details

I. General information

NPI: 1962842609
Provider Name (Legal Business Name): STEPHANIE NICOLE DAUGHERTY OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE NICOLE GREEN

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 03/25/2020
Certification Date: 03/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 EDWIN ST
MORGANTOWN WV
26501-8505
US

IV. Provider business mailing address

6 EDWIN ST
MORGANTOWN WV
26501-8505
US

V. Phone/Fax

Practice location:
  • Phone: 304-292-0173
  • Fax: 304-292-0174
Mailing address:
  • Phone: 304-292-0173
  • Fax: 304-292-0174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberLPT357
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1648
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: