Provider Demographics
NPI:1649585316
Name:DILL, MARY ALEX (LGSW)
Entity type:Individual
Prefix:MRS
First Name:MARY ALEX
Middle Name:
Last Name:DILL
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:ALEXANDRA
Other - Last Name:DILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LGSW
Mailing Address - Street 1:317 HOSPITAL ST
Mailing Address - Street 2:
Mailing Address - City:MOULTON
Mailing Address - State:AL
Mailing Address - Zip Code:35650-1269
Mailing Address - Country:US
Mailing Address - Phone:256-974-6697
Mailing Address - Fax:
Practice Address - Street 1:295 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:MOULTON
Practice Address - State:AL
Practice Address - Zip Code:35650-1210
Practice Address - Country:US
Practice Address - Phone:256-974-6697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3021G101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health