Provider Demographics
NPI:1043752017
Name:DODSON, MICHELE DIANE (LLBSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:DIANE
Last Name:DODSON
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:DIANE
Other - Last Name:MAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2941 S GULLEY RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3160
Mailing Address - Country:US
Mailing Address - Phone:313-278-3040
Mailing Address - Fax:
Practice Address - Street 1:2941 S GULLEY RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3160
Practice Address - Country:US
Practice Address - Phone:313-278-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802089266104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker