Provider Demographics
NPI:1043580830
Name:DORETY, DIANA BETH (MA)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:BETH
Last Name:DORETY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 VICTORIA PL
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-3865
Mailing Address - Country:US
Mailing Address - Phone:405-341-1987
Mailing Address - Fax:
Practice Address - Street 1:1909 VICTORIA PL
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-3865
Practice Address - Country:US
Practice Address - Phone:405-606-5768
Practice Address - Fax:405-917-5595
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3839235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist