Provider Demographics
NPI:1487650362
Name:DYGERT, MARY CYNTHIA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CYNTHIA
Last Name:DYGERT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:DYGERT
Other - Last Name:BEAVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:850 N HARRISON ST
Mailing Address - Street 2:ATTN: ANNE LAWSON
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3163
Mailing Address - Country:US
Mailing Address - Phone:574-267-7169
Mailing Address - Fax:574-268-2377
Practice Address - Street 1:119 W MARKET ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-2311
Practice Address - Country:US
Practice Address - Phone:260-248-8176
Practice Address - Fax:260-248-2366
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001958A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200283190AMedicaid
IN452240CMedicare ID - Type UnspecifiedPROVIDER ID