Provider Demographics
NPI:1083107155
Name:MABEN, DOROTHY LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:LYNN
Last Name:MABEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SANTA ROSA COUNTY JAIL/WELLPATH
Mailing Address - Street 2:5755 E. MILTON ROAD
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583
Mailing Address - Country:US
Mailing Address - Phone:850-983-1129
Mailing Address - Fax:
Practice Address - Street 1:5755 E MILTON RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-7913
Practice Address - Country:US
Practice Address - Phone:850-983-1129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW149631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical