Provider Demographics
NPI:1245562529
Name:DOTY, JUSTIN ROBERT (MED, LPC)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ROBERT
Last Name:DOTY
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2665 FOUR LAKES DR
Mailing Address - Street 2:
Mailing Address - City:BLANCHARD
Mailing Address - State:OK
Mailing Address - Zip Code:73010-8922
Mailing Address - Country:US
Mailing Address - Phone:405-323-0548
Mailing Address - Fax:
Practice Address - Street 1:2665 FOUR LAKES DR
Practice Address - Street 2:
Practice Address - City:BLANCHARD
Practice Address - State:OK
Practice Address - Zip Code:73010-8922
Practice Address - Country:US
Practice Address - Phone:405-323-0548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-11
Last Update Date:2023-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4321101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional