Provider Demographics
NPI:1013960004
Name:TUSHMAN, DALE MYRA (LCSW)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:MYRA
Last Name:TUSHMAN
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 1:100 MARINERS DR STE D
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-6667
Mailing Address - Country:US
Mailing Address - Phone:912-510-0669
Mailing Address - Fax:912-510-0754
Practice Address - Street 1:100 MARINERS DR STE D
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6667
Practice Address - Country:US
Practice Address - Phone:912-510-0669
Practice Address - Fax:912-510-0754
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW 0019451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003219987AMedicaid
GA80BBGGKMedicare ID - Type Unspecified