Basic Information
| Provider Information | |||||||||
| NPI: | 1598370223 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAUGHERTY | ||||||||
| FirstName: | CARMELITA | ||||||||
| MiddleName: | D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 HAWTHORNE LN | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461429430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173329861 | ||||||||
| FaxNumber: | 3178934453 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 HAWTHORNE LN | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461429430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173329861 | ||||||||
| FaxNumber: | 3178934453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2020 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 31003406A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.