Basic Information
| Provider Information | |||||||||
| NPI: | 1811211832 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOTY | ||||||||
| FirstName: | GLENN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23950 PRADO LN | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923249734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095141958 | ||||||||
| FaxNumber: | 7603228916 | ||||||||
| Practice Location | |||||||||
| Address1: | 23950 PRADO LN | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923249734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095141958 | ||||||||
| FaxNumber: | 7603228916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2010 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | C054600518 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.