Provider Demographics
NPI:1205277977
Name:FORTICH, DAWN M (LCSW)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:M
Last Name:FORTICH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31569
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37930-1569
Mailing Address - Country:US
Mailing Address - Phone:865-212-6600
Mailing Address - Fax:865-313-2149
Practice Address - Street 1:194 MARKET PLACE BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922
Practice Address - Country:US
Practice Address - Phone:865-212-6600
Practice Address - Fax:865-313-2149
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000049901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1533131Medicaid