Provider Demographics
NPI:1235145426
Name:DOTY, DONALD ALLEN (PHD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:ALLEN
Last Name:DOTY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 S ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-8362
Mailing Address - Country:US
Mailing Address - Phone:618-457-4488
Mailing Address - Fax:618-457-8844
Practice Address - Street 1:3412 S ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62903-8362
Practice Address - Country:US
Practice Address - Phone:618-457-4488
Practice Address - Fax:618-457-8844
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL731371Medicare ID - Type Unspecified