Provider Demographics
NPI:1649730490
Name:KIRBY, DORTHEA MORNET (SF)
Entity type:Individual
Prefix:
First Name:DORTHEA
Middle Name:MORNET
Last Name:KIRBY
Suffix:
Gender:F
Credentials:SF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3090 BASSETT HEIGHTS ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:BASSETT
Mailing Address - State:VA
Mailing Address - Zip Code:24055-4812
Mailing Address - Country:US
Mailing Address - Phone:276-252-1043
Mailing Address - Fax:276-293-1178
Practice Address - Street 1:3090 BASSETT HEIGHTS ROAD EXT
Practice Address - Street 2:
Practice Address - City:BASSETT
Practice Address - State:VA
Practice Address - Zip Code:24055-4812
Practice Address - Country:US
Practice Address - Phone:276-252-1043
Practice Address - Fax:276-293-1178
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1073997953Medicaid