MEDICARE: LAURA GRACE DAUGHERTY PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2019039637	MO

General Provider Information

NPI Number	:	1679113633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA GRACE DAUGHERTY PTA

Provider Business Mailing Address
First Line	:	506 UPLAND CREEK RD
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65201-6773
Country	:	US
Telephone Number	:	573-324-7061
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 NW VESPER ST
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64014-2745
Country	:	US
Telephone Number	:	877-787-3430
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2020
Last Update Date	:	10/29/2024

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Directions to “ LAURA GRACE DAUGHERTY PTA” Practice Location

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