Provider Demographics
NPI:1811009954
Name:DODGE, MARY S (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:S
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 1:2601 W 4TH ST
Mailing Address - Street 2:P.O. BOX 2610
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-3309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:406 S BEDFORD ST
Practice Address - Street 2:STE 9
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-1850
Practice Address - Country:US
Practice Address - Phone:302-856-9578
Practice Address - Fax:302-856-6297
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00005761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000023538Medicaid
DE1000023538Medicaid