Provider Demographics
NPI:1215119367
Name:ANDERLY-DOTSON, AMY JO (LADC, LICSW)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JO
Last Name:ANDERLY-DOTSON
Suffix:
Gender:
Credentials:LADC, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 SAILSTAR DR NW
Mailing Address - Street 2:
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633
Mailing Address - Country:US
Mailing Address - Phone:218-335-3050
Mailing Address - Fax:218-335-4410
Practice Address - Street 1:190 SAILSTAR DR NW
Practice Address - Street 2:
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633
Practice Address - Country:US
Practice Address - Phone:218-335-3050
Practice Address - Fax:218-335-4410
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302225101YA0400X
MN18704101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health