Healthcare Provider Details

I. General information

NPI: 1376082230
Provider Name (Legal Business Name): DEIDRE DOTSON LLBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DEIDRE WELLHOUSEN LLBSW

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 S EUCLID
BAY CITY MI
48706
US

IV. Provider business mailing address

1217 S EUCLID
BAY CITY MI
48706
US

V. Phone/Fax

Practice location:
  • Phone: 989-667-9661
  • Fax: 989-667-9680
Mailing address:
  • Phone: 989-667-9661
  • Fax: 989-667-9680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802088454
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: