Provider Demographics
NPI:1023201035
Name:DORSEY, MIESHA D (LBA, BCBA)
Entity Type:Individual
Prefix:
First Name:MIESHA
Middle Name:D
Last Name:DORSEY
Suffix:
Gender:F
Credentials:LBA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5323 LEVANDER LOOP
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-5146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5323 LEVANDER LOOP
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-5146
Practice Address - Country:US
Practice Address - Phone:313-999-6984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803085593171M00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6803085593OtherCASE MANAGER
IL1023201035Medicaid