Basic Information
| Provider Information | |||||||||
| NPI: | 1063545424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAUGHERTY | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1829 EAST FRANKLIN STREET | ||||||||
| Address2: | BLDG. # 600 | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199683456 | ||||||||
| FaxNumber: | 9199323456 | ||||||||
| Practice Location | |||||||||
| Address1: | 1829 EAST FRANKLIN STREET | ||||||||
| Address2: | BLDG. # 600 | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199683456 | ||||||||
| FaxNumber: | 9199323456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 4987 | NC | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XP0200X | 4987 | NC | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7301786 | 05 | NC | MEDICAID | 1387G | 01 | NC | BLUE CROSS | OTHER |