Provider Demographics
NPI:1164573804
Name:DOTSON, VIRGINIA LOUISE (PHD)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:LOUISE
Last Name:DOTSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:VIRGINIA
Other - Middle Name:LOUISE
Other - Last Name:DOTSON-KOCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:6110 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4308
Mailing Address - Country:US
Mailing Address - Phone:414-332-2074
Mailing Address - Fax:414-332-2583
Practice Address - Street 1:6110 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-4308
Practice Address - Country:US
Practice Address - Phone:414-332-2074
Practice Address - Fax:414-332-2583
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1108103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0000846750Medicare ID - Type Unspecified