Provider Demographics
NPI:1083176531
Name:FORTSON, DOLORES R (MSW CDCA)
Entity Type:Individual
Prefix:
First Name:DOLORES
Middle Name:R
Last Name:FORTSON
Suffix:
Gender:F
Credentials:MSW CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5104 QUINCY AVE APT 2139
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-1244
Mailing Address - Country:US
Mailing Address - Phone:216-235-7540
Mailing Address - Fax:
Practice Address - Street 1:2532 E 86TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-2244
Practice Address - Country:US
Practice Address - Phone:216-456-6957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH163220101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)