Provider Demographics
NPI:1578514394
Name:DOTSON, KIMBERLEY W
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:W
Last Name:DOTSON
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 1:5000 CHESHIRE PKWY N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-4103
Mailing Address - Country:US
Mailing Address - Phone:763-268-4115
Mailing Address - Fax:763-268-4430
Practice Address - Street 1:15405 SW 116TH AVE
Practice Address - Street 2:STE 200
Practice Address - City:KING CITY
Practice Address - State:OR
Practice Address - Zip Code:97224-2600
Practice Address - Country:US
Practice Address - Phone:503-684-1583
Practice Address - Fax:503-598-8471
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21942231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR116935Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER