Provider Demographics
NPI:1336277540
Name:DOTHAN BEHAVIORAL MEDICINE CLINIC PC
Entity Type:Organization
Organization Name:DOTHAN BEHAVIORAL MEDICINE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-702-7222
Mailing Address - Street 1:101 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-6903
Mailing Address - Country:US
Mailing Address - Phone:334-702-7222
Mailing Address - Fax:334-702-1944
Practice Address - Street 1:408 HEALTHWEST DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-2054
Practice Address - Country:US
Practice Address - Phone:334-702-7222
Practice Address - Fax:334-702-1944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL199432084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========Medicaid
J422Medicare UPIN
AL=========Medicaid