Provider Demographics
NPI:1497005755
Name:DORITY, JOHNNY DALE I (BHRS)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:DALE
Last Name:DORITY
Suffix:I
Gender:M
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-6841
Mailing Address - Country:US
Mailing Address - Phone:918-708-6169
Mailing Address - Fax:
Practice Address - Street 1:907 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-6841
Practice Address - Country:US
Practice Address - Phone:918-708-6169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health