Provider Demographics
NPI:1760573257
Name:DODGE, MICHELLE ANNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:ANNE
Last Name:DODGE
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 1:146 W CIRCLE CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-3877
Mailing Address - Country:US
Mailing Address - Phone:910-670-6018
Mailing Address - Fax:910-396-8745
Practice Address - Street 1:DA WAMC STOP A 2817 REILLY RD
Practice Address - Street 2:MCXC DSW
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-7301
Practice Address - Country:US
Practice Address - Phone:910-907-9648
Practice Address - Fax:910-396-8745
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1630C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical