Provider Demographics
NPI:1336293695
Name:LODER, CORY (LICSW)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:LODER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 MILLER VIEW ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTH EGREMONT
Mailing Address - State:MA
Mailing Address - Zip Code:01252
Mailing Address - Country:US
Mailing Address - Phone:413-528-9285
Mailing Address - Fax:
Practice Address - Street 1:25 COTTAGE ST
Practice Address - Street 2:BRIEN CENTER MAIN ST. HUMAN RESOURCES
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1329
Practice Address - Country:US
Practice Address - Phone:413-528-9155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1062961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA31711OtherHEALTH NEW ENGLAND
MAP04922OtherBLUE CROSS BLUE SHIELD
MAP04922Medicare ID - Type UnspecifiedMEDICARE