Provider Demographics
NPI:1700199346
Name:DOLAN, MARTHA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:
Last Name:DOLAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MARTHA
Other - Middle Name:DOLAN
Other - Last Name:GREGG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:10010 KENNERLY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2106
Mailing Address - Country:US
Mailing Address - Phone:314-525-4412
Mailing Address - Fax:314-525-4420
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:314-525-4412
Practice Address - Fax:314-525-4420
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-25
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW0013571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical