Provider Demographics
NPI:1609888387
Name:DODGE, SUSAN SHIRING (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:SHIRING
Last Name:DODGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:J
Other - Last Name:SHIRING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 638
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75783-0638
Mailing Address - Country:US
Mailing Address - Phone:214-808-1543
Mailing Address - Fax:
Practice Address - Street 1:4925 GREENVILLE AVE STE 1125
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-0501
Practice Address - Country:US
Practice Address - Phone:972-918-0170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21865101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX609930Medicare ID - Type Unspecified