Healthcare Provider Details

I. General information

NPI: 1407750664
Provider Name (Legal Business Name): SOUTHALL DORSEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SKYPP DORSEY

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6006 N 58TH ST
OMAHA NE
68104-1261
US

IV. Provider business mailing address

4805 N 72ND ST
OMAHA NE
68134-2304
US

V. Phone/Fax

Practice location:
  • Phone: 402-213-9010
  • Fax:
Mailing address:
  • Phone: 402-571-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number253J00000X
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: