Provider Demographics
NPI:1851654339
Name:DOTSON, MARY SUSAN
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SUSAN
Last Name:DOTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:SUSAN
Other - Last Name:SCHOOLCRAFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3295 BABYLON RD
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-9287
Mailing Address - Country:US
Mailing Address - Phone:269-355-1199
Mailing Address - Fax:
Practice Address - Street 1:3295 BABYLON RD
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-9287
Practice Address - Country:US
Practice Address - Phone:269-355-1199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF030314952320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities