Provider Demographics
NPI:1821194911
Name:HARDWICK, JODI SUSANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:SUSANNE
Last Name:HARDWICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:SUSANNE
Other - Last Name:MONEBRAKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1 VA CENTER (MDP171)
Mailing Address - Street 2:TOGUS VAMC
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330
Mailing Address - Country:US
Mailing Address - Phone:207-623-8411
Mailing Address - Fax:207-626-4707
Practice Address - Street 1:1 VA CENTER (MDP171)
Practice Address - Street 2:TOGUS VAMC
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330
Practice Address - Country:US
Practice Address - Phone:207-623-8411
Practice Address - Fax:207-626-4707
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC10617106H00000X
MELC125171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432299199Medicare ID - Type Unspecified