Provider Demographics
NPI:1376978403
Name:DOTY, WALTER LEE IV (MS)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:LEE
Last Name:DOTY
Suffix:IV
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-5714
Mailing Address - Country:US
Mailing Address - Phone:402-290-8537
Mailing Address - Fax:
Practice Address - Street 1:3103 8TH AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-5714
Practice Address - Country:US
Practice Address - Phone:402-290-8537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001625101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health