Provider Demographics
NPI:1437462017
Name:DAUGHERTY, DIANA LEIGH (AUD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:LEIGH
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 SUITE C MARKET PLACE MALL
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452
Mailing Address - Country:US
Mailing Address - Phone:304-517-1401
Mailing Address - Fax:304-517-1404
Practice Address - Street 1:456 SUITE C MARKET PLACE MALL
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452
Practice Address - Country:US
Practice Address - Phone:304-517-1401
Practice Address - Fax:304-517-1404
Is Sole Proprietor?:No
Enumeration Date:2010-07-23
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVA0268231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810018309Medicaid
7416691Medicare PIN