Provider Demographics
NPI:1104835750
Name:MISTER, DORNELL (SOCIAL WORK)
Entity type:Individual
Prefix:MR
First Name:DORNELL
Middle Name:
Last Name:MISTER
Suffix:
Gender:M
Credentials:SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 GLENRIDGE WAY
Mailing Address - Street 2:APT #48
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792
Mailing Address - Country:US
Mailing Address - Phone:407-629-1599
Mailing Address - Fax:407-599-1472
Practice Address - Street 1:5201 5201 RAYMOND ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803
Practice Address - Country:US
Practice Address - Phone:407-629-1599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2-00571101YA0400X
MI6802072553104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker