Provider Demographics
NPI:1710040993
Name:LODGE, ELLEN SUSAN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:SUSAN
Last Name:LODGE
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:PO BOX 6395
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93412-6395
Mailing Address - Country:US
Mailing Address - Phone:805-264-4050
Mailing Address - Fax:805-534-1967
Practice Address - Street 1:6470 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-4229
Practice Address - Country:US
Practice Address - Phone:805-264-4050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA191871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical