MEDICARE: LESLIE DAUGHERTY LMFT

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	106H00000X	Marriage & Family Therapist	15354	AZ
2	106H00000X	Marriage & Family Therapist	85341	CA

General Provider Information

NPI Number	:	1831379353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE DAUGHERTY LMFT

Provider Business Mailing Address
First Line	:	7600 N 15TH ST STE 150
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85020-4305
Country	:	US
Telephone Number	:	480-463-4015
Fax Number	:

Provider Business Practice Location Address
First Line	:	7600 N 15TH ST STE 150
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85020-4305
Country	:	US
Telephone Number	:	480-463-4015
Fax Number	:

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

Provider Enumeration Date	:	11/13/2007
Last Update Date	:	02/06/2022

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