Provider Demographics
NPI:1437663655
Name:DORTCH, CHARNELL
Entity type:Individual
Prefix:
First Name:CHARNELL
Middle Name:
Last Name:DORTCH
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 1:16119 FENMORE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3420
Mailing Address - Country:US
Mailing Address - Phone:313-247-8738
Mailing Address - Fax:
Practice Address - Street 1:16119 FENMORE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3420
Practice Address - Country:US
Practice Address - Phone:313-247-8738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014696101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health