Healthcare Provider Details

I. General information

NPI: 1811368681
Provider Name (Legal Business Name): TROY DORMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4576 E SHIELDS AVE
FRESNO CA
93726-7220
US

IV. Provider business mailing address

1009 MCHENRY AVE STE E
MODESTO CA
95350-5446
US

V. Phone/Fax

Practice location:
  • Phone: 209-575-1580
  • Fax: 209-575-2017
Mailing address:
  • Phone: 209-575-1580
  • Fax: 209-575-2017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: