MEDICARE: MEGAN GRACE DAUGHERTY

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

General Provider Information

NPI Number	:	1699587097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEGAN GRACE DAUGHERTY

Provider Business Mailing Address
First Line	:	14627 S BONNIE JEAN LN
Second Line	:
City	:	HERRIMAN
State	:	UT
Zip	:	84096-1239
Country	:	US
Telephone Number	:	385-321-3631
Fax Number	:

Provider Business Practice Location Address
First Line	:	1787 E FORT UNION BLVD STE 101
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-2868
Country	:	US
Telephone Number	:	385-526-3925
Fax Number	:

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

Provider Enumeration Date	:	01/22/2025
Last Update Date	:	01/22/2025

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Directions to “ MEGAN GRACE DAUGHERTY ” Practice Location

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