Basic Information
| Provider Information | |||||||||
| NPI: | 1346473691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOTSON | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHISHOLM | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1843 RW BERENDS DR SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495194955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167732908 | ||||||||
| FaxNumber: | 6169493018 | ||||||||
| Practice Location | |||||||||
| Address1: | 1843 RW BERENDS DR SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495194955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167732908 | ||||||||
| FaxNumber: | 6169493018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2009 | ||||||||
| LastUpdateDate: | 01/03/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801091245 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.