Provider Demographics
NPI:1083988133
Name:DILLARD, MICHELLE A (LCSW-C, LICSW)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:A
Last Name:DILLARD
Suffix:
Gender:F
Credentials:LCSW-C, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11705 BERRY RD STE 104
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-5933
Mailing Address - Country:US
Mailing Address - Phone:240-207-4513
Mailing Address - Fax:240-846-6037
Practice Address - Street 1:11705 BERRY RD STE 104
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-5933
Practice Address - Country:US
Practice Address - Phone:140-207-4513
Practice Address - Fax:240-846-6037
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500779931041C0700X
VA09040094611041C0700X
MD126141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD875303200Medicaid