=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699579730
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLY DAUGHERTY, LCSW, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2025
-----------------------------------------------------
Last Update Date | 04/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 SARATOGA VILLAGE BLVD STE 21
-----------------------------------------------------
City | MALTA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12020-3703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-219-8625
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 118 WHITE RD
-----------------------------------------------------
City | BALLSTON SPA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12020-2120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-219-8625
-----------------------------------------------------
Fax | 518-309-6599
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KELLY DAUGHERTY
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 518-219-8625
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------