Provider Demographics
NPI:1750037941
Name:DOTSON KEITH, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:DOTSON KEITH
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 1:7 RIDGEVIEW DR SE
Mailing Address - Street 2:
Mailing Address - City:SILVER CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30173-2327
Mailing Address - Country:US
Mailing Address - Phone:706-676-0789
Mailing Address - Fax:706-295-2267
Practice Address - Street 1:808 AVENUE B NE STE D
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2746
Practice Address - Country:US
Practice Address - Phone:706-295-2498
Practice Address - Fax:706-295-2267
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAL-307747174N00000X
GARBT-22-198474106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No174N00000XOther Service ProvidersLactation Consultant, Non-RN