Provider Demographics
NPI:1326410028
Name:DORSTEN, KATHLEEN E (IMFT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:E
Last Name:DORSTEN
Suffix:
Gender:F
Credentials:IMFT
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:E
Other - Last Name:ROLLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IMFT
Mailing Address - Street 1:37 IRONGATE PARK DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4616
Mailing Address - Country:US
Mailing Address - Phone:937-907-0393
Mailing Address - Fax:
Practice Address - Street 1:37 IRONGATE PARK DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459
Practice Address - Country:US
Practice Address - Phone:937-907-0393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF.1500013101YM0800X, 106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH01-0693OtherCARF CERTIFICATION
OHH130910OtherMEDICARE GROUP PTAN
OH0074861OtherOHIO DEPT. ALCOHOL DRUG ADDICTION SERVICES (ODADAS) GROUP
OH0074946OtherOHIO DEPT. MENTAL HEALTH (GROUP)