Provider Demographics
NPI:1912203076
Name:DOTSON, VONETTA MICHELLE (PHD)
Entity Type:Individual
Prefix:
First Name:VONETTA
Middle Name:MICHELLE
Last Name:DOTSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3328 E PONCE DE LEON AVE UNIT 437
Mailing Address - Street 2:
Mailing Address - City:SCOTTDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30079
Mailing Address - Country:US
Mailing Address - Phone:404-482-3898
Mailing Address - Fax:
Practice Address - Street 1:2752 E PONCE DE LEON AVE STE G
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2714
Practice Address - Country:US
Practice Address - Phone:404-482-3898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-07
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004288103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEV604ZMedicare PIN