Provider Demographics
NPI:1639296163
Name:DOTSON, STEPHANIE (PT)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:DOTSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4364
Mailing Address - Country:US
Mailing Address - Phone:309-664-3420
Mailing Address - Fax:309-664-3422
Practice Address - Street 1:1701 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2101
Practice Address - Country:US
Practice Address - Phone:309-664-3420
Practice Address - Fax:309-664-3422
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009899225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203OtherBLUE CROSS PROV ID
7216OtherPERSONALCARE PROV ID
IL4117OtherHAMP PROVIDER ID
113326OtherHEALTHLINK PROV ID
140091Medicare ID - Type Unspecified