Provider Demographics
NPI:1568559219
Name:LODGE, JOAN M (LCSW)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:LODGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:526 W STATE STREET
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-1214
Mailing Address - Country:US
Mailing Address - Phone:815-968-9300
Mailing Address - Fax:815-968-5314
Practice Address - Street 1:475 SOUTHTOWNE DR
Practice Address - Street 2:JANET WATTLES CENTER
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-5643
Practice Address - Country:US
Practice Address - Phone:815-544-4849
Practice Address - Fax:815-544-2116
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical