Provider Demographics
NPI:1013939131
Name:DODY WARNOCK, MARY ELIZABETH (LMSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:DODY WARNOCK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:DODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:12265 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8613
Mailing Address - Country:US
Mailing Address - Phone:616-494-5453
Mailing Address - Fax:
Practice Address - Street 1:1111 FULTON ST
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1569
Practice Address - Country:US
Practice Address - Phone:616-846-8235
Practice Address - Fax:616-842-0886
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010333911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104948647Medicaid
MI104948647Medicaid