Provider Demographics
NPI:1114492956
Name:DODSON, MARY BERGENS (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BERGENS
Last Name:DODSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:BERGENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16109 S APRIL DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4181
Mailing Address - Country:US
Mailing Address - Phone:985-774-4076
Mailing Address - Fax:228-385-5165
Practice Address - Street 1:2620 EXECUTIVE PL
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-3717
Practice Address - Country:US
Practice Address - Phone:228-385-7744
Practice Address - Fax:228-385-5165
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST0510101YM0800X, 171M00000X, 251B00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management