Provider Demographics
NPI:1083980551
Name:STODDARD, MARY LUCILLE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LUCILLE
Last Name:STODDARD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 ALFA CT APT 1A
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-2979
Mailing Address - Country:US
Mailing Address - Phone:989-305-2095
Mailing Address - Fax:
Practice Address - Street 1:745 ALFA CT APT 1A
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-2979
Practice Address - Country:US
Practice Address - Phone:989-305-2095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008403251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health