Basic Information
| Provider Information | |||||||||
| NPI: | 1740870385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DORTON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | COUNSELOR TECHNICIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 73658 | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997073658 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3100 S CUSHMAN ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997017516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074526251 | ||||||||
| FaxNumber: | 9074564849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2021 | ||||||||
| LastUpdateDate: | 01/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 4518 | AK | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.