Provider Demographics
NPI:1023716545
Name:MOTLEY, DEDOSHA
Entity type:Individual
Prefix:
First Name:DEDOSHA
Middle Name:
Last Name:MOTLEY
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 1:278 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-1764
Mailing Address - Country:US
Mailing Address - Phone:419-688-1323
Mailing Address - Fax:
Practice Address - Street 1:278 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-1764
Practice Address - Country:US
Practice Address - Phone:419-688-1323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health