Healthcare Provider Details

I. General information

NPI: 1336277540
Provider Name (Legal Business Name): DOTHAN BEHAVIORAL MEDICINE CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 HEALTHWEST DR
DOTHAN AL
36303-2054
US

IV. Provider business mailing address

101 MEDICAL DR
DOTHAN AL
36303-6903
US

V. Phone/Fax

Practice location:
  • Phone: 334-702-7222
  • Fax: 334-702-1944
Mailing address:
  • Phone: 334-702-7222
  • Fax: 334-702-1944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number19943
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. TAMI JOHSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 334-702-7222