MEDICARE: DOLORES R FORTSON MSW. CDCA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	163220	OH

General Provider Information

NPI Number	:	1083176531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOLORES R FORTSON MSW. CDCA

Provider Business Mailing Address
First Line	:	5104 QUINCY AVE APT 2139
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44104-1244
Country	:	US
Telephone Number	:	216-235-7540
Fax Number	:

Provider Business Practice Location Address
First Line	:	2532 E 86TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44104-2244
Country	:	US
Telephone Number	:	216-456-6957
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2019
Last Update Date	:	04/03/2019

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