Provider Demographics
NPI:1437893781
Name:DOTHAGER, MICHELLE DAWN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DAWN
Last Name:DOTHAGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 HOCKETT BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-3462
Mailing Address - Country:US
Mailing Address - Phone:618-910-2205
Mailing Address - Fax:
Practice Address - Street 1:664 HOCKETT BRIDGE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-3462
Practice Address - Country:US
Practice Address - Phone:618-910-2205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490204951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical