Provider Demographics
NPI:1871928606
Name:MCBRIDE, DORETHA MICHELE (LCSW, CADC)
Entity type:Individual
Prefix:MS
First Name:DORETHA
Middle Name:MICHELE
Last Name:MCBRIDE
Suffix:
Gender:F
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 MILLIFIORA LN
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759-4336
Mailing Address - Country:US
Mailing Address - Phone:219-226-5567
Mailing Address - Fax:863-496-5338
Practice Address - Street 1:509 MILLIFIORA LN
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34759-4336
Practice Address - Country:US
Practice Address - Phone:219-226-5567
Practice Address - Fax:863-496-5338
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL22796101YA0400X
IL149.0157751041C0700X
IN34007000A1041C0700X
FLSW169331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400184005Medicare PIN