1194860346 NPI number — MRS. ANITA R GANTRY DOTSON MS SLP A CCC

Table of content: MRS. ANITA R GANTRY DOTSON MS SLP A CCC (NPI 1194860346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194860346 NPI number — MRS. ANITA R GANTRY DOTSON MS SLP A CCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANTRY DOTSON
Provider First Name:
ANITA
Provider Middle Name:
R
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS SLP A CCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194860346
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1570 N NATIONAL
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CHEHALIS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-740-8992
Provider Business Mailing Address Fax Number:
360-740-8993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1570 N NATIONAL
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CHEHALIS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-740-8992
Provider Business Practice Location Address Fax Number:
360-740-8993
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  LD00001112 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 235Z00000X , with the licence number: LL00001021 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 237700000X , with the licence number: HA00000691 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0030177 . This is a "L&I WORKMANS COMP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7100746 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7035900 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: LL00001021 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: HEARINGAIDS9035742 . This is a "DSHS" identifier . This identifiers is of the category "OTHER".




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