Healthcare Provider Details

I. General information

NPI: 1427156785
Provider Name (Legal Business Name): JAMES ANTHONY DORETHY MSW,LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 BUTTERCUP DR
MOUNTAIN HOME AR
72653-2910
US

IV. Provider business mailing address

2599 TUCKER CEMETARY RD
GASSVILLE AR
72635-8730
US

V. Phone/Fax

Practice location:
  • Phone: 870-508-8614
  • Fax: 501-257-3164
Mailing address:
  • Phone: 870-508-8614
  • Fax: 501-257-3164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1566-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: