Provider Demographics
NPI:1568827467
Name:DODGE, MARYLOU
Entity Type:Individual
Prefix:
First Name:MARYLOU
Middle Name:
Last Name:DODGE
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 1:120 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-2203
Mailing Address - Country:US
Mailing Address - Phone:413-731-3730
Mailing Address - Fax:
Practice Address - Street 1:120 MAPLE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2203
Practice Address - Country:US
Practice Address - Phone:413-731-3730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-18
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1193261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical