Provider Demographics
NPI:1619017456
Name:LOHSE, MARY C (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:LOHSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4626 SW OTT CT
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6643
Mailing Address - Country:US
Mailing Address - Phone:772-224-6610
Mailing Address - Fax:772-237-4812
Practice Address - Street 1:4626 SW OTT CT
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-6643
Practice Address - Country:US
Practice Address - Phone:772-224-6610
Practice Address - Fax:772-237-4812
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDA330AOtherMEDICARE PTAN