Provider Demographics
NPI:1497731939
Name:DEBRODIE, MARY BETH (LCSW, PHD)
Entity Type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:DEBRODIE
Suffix:
Gender:F
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:BETH
Other - Last Name:COMMISSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 456
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65010
Mailing Address - Country:US
Mailing Address - Phone:573-220-8366
Mailing Address - Fax:
Practice Address - Street 1:601 W NIFONG, BLDG. 5A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203
Practice Address - Country:US
Practice Address - Phone:573-220-8366
Practice Address - Fax:573-592-8929
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003018483104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498394238Medicaid