Provider Demographics
NPI:1679633895
Name:DORSON, CARRIE MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:MARIE
Last Name:DORSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 MOCKINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2018
Mailing Address - Country:US
Mailing Address - Phone:940-642-3530
Mailing Address - Fax:
Practice Address - Street 1:149 HART ST
Practice Address - Street 2:82 MEDICAL GROUP SGH
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311-3477
Practice Address - Country:US
Practice Address - Phone:940-676-6075
Practice Address - Fax:940-676-6076
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1189103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXVAD 000Medicare UPIN