Provider Demographics
NPI:1639734767
Name:MCNEAL, DOTRALEE (CBHCM)
Entity Type:Individual
Prefix:
First Name:DOTRALEE
Middle Name:
Last Name:MCNEAL
Suffix:
Gender:F
Credentials:CBHCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 S PARK AVE APT 901
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-3958
Mailing Address - Country:US
Mailing Address - Phone:352-431-6337
Mailing Address - Fax:
Practice Address - Street 1:835 SYCAMORE ST # H8
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-7700
Practice Address - Country:US
Practice Address - Phone:352-431-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-03
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCM102301171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCBHCM102301Medicaid