Provider Demographics
NPI:1811368681
Name:DORMAN, TROY
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:
Last Name:DORMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 MCHENRY AVE
Mailing Address - Street 2:STE E
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5446
Mailing Address - Country:US
Mailing Address - Phone:209-575-1580
Mailing Address - Fax:209-575-2017
Practice Address - Street 1:4576 E SHIELDS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-7220
Practice Address - Country:US
Practice Address - Phone:209-575-1580
Practice Address - Fax:209-575-2017
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)