Healthcare Provider Details

I. General information

NPI: 1619696085
Provider Name (Legal Business Name): DEANNA MARIE DOTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3665 N BROADWAY ST
CHICAGO IL
60613-4567
US

IV. Provider business mailing address

101 46TH AVE
BELLWOOD IL
60104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 773-496-4433
  • Fax:
Mailing address:
  • Phone: 708-488-7240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: