Provider Demographics
NPI:1821726324
Name:DAGENHART, MARY COBURN (MA, LCMHC-A)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:COBURN
Last Name:DAGENHART
Suffix:
Gender:F
Credentials:MA, LCMHC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 BRANTLEY ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3709
Mailing Address - Country:US
Mailing Address - Phone:336-971-7434
Mailing Address - Fax:
Practice Address - Street 1:8025 N POINT BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3262
Practice Address - Country:US
Practice Address - Phone:336-896-0065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17870101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health