Healthcare Provider Details

I. General information

NPI: 1184539397
Provider Name (Legal Business Name): KENNETH MATTHEW DOTSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 BRUNSWICK ST
SAN FRANCISCO CA
94112-4202
US

IV. Provider business mailing address

146 CATHY ELLEN DR.
VALLEJO CA
94591
US

V. Phone/Fax

Practice location:
  • Phone: 415-337-4065
  • Fax:
Mailing address:
  • Phone: 209-990-6592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRT1449500726
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: