Provider Demographics
NPI:1851659098
Name:DORTCH, TEIDRA J (PC)
Entity Type:Individual
Prefix:
First Name:TEIDRA
Middle Name:J
Last Name:DORTCH
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 W BOWERY ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44307-2598
Mailing Address - Country:US
Mailing Address - Phone:330-996-4600
Mailing Address - Fax:330-643-0767
Practice Address - Street 1:282 W BOWERY ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44307-2598
Practice Address - Country:US
Practice Address - Phone:330-996-4600
Practice Address - Fax:330-643-0767
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC 1000547101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health