Provider Demographics
NPI:1659667319
Name:DAUGHERTY, DENNIS ALLEN (MFT)
Entity type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:ALLEN
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4707 COTTAGE WAY
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-5610
Mailing Address - Country:US
Mailing Address - Phone:916-488-4567
Mailing Address - Fax:
Practice Address - Street 1:4545 9TH AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-1421
Practice Address - Country:US
Practice Address - Phone:916-736-0828
Practice Address - Fax:916-736-0395
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48676106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist