Healthcare Provider Details

I. General information

NPI: 1245562529
Provider Name (Legal Business Name): JUSTIN ROBERT DOTY M.ED., LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2010
Last Update Date: 11/19/2023
Certification Date: 11/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2665 FOUR LAKES DR
BLANCHARD OK
73010-8922
US

IV. Provider business mailing address

2665 FOUR LAKES DR
BLANCHARD OK
73010-8922
US

V. Phone/Fax

Practice location:
  • Phone: 405-323-0548
  • Fax:
Mailing address:
  • Phone: 405-323-0548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4321
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: