Provider Demographics
NPI:1710865613
Name:DORTCH, DESMOND N
Entity type:Individual
Prefix:
First Name:DESMOND
Middle Name:N
Last Name:DORTCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26527 OPAL ST # A
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-3821
Mailing Address - Country:US
Mailing Address - Phone:951-630-7914
Mailing Address - Fax:
Practice Address - Street 1:26527 OPAL ST # A
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3821
Practice Address - Country:US
Practice Address - Phone:951-630-7914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician