Provider Demographics
NPI:1407913387
Name:DODGEN, MAUREEN W
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:W
Last Name:DODGEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 STEDMAN LN SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-4767
Mailing Address - Country:US
Mailing Address - Phone:770-761-0514
Mailing Address - Fax:770-784-3187
Practice Address - Street 1:175 KIRKLAND RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-3317
Practice Address - Country:US
Practice Address - Phone:770-784-3188
Practice Address - Fax:770-784-3187
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health