Provider Demographics
NPI:1922407709
Name:DAUGHERTY, MARILYN (SLPA)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17019 E CALLE DEL ORO APT A
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-2456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5314 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2805
Practice Address - Country:US
Practice Address - Phone:602-277-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA90082355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant