MEDICARE: DR. MICHELLE A DILLARD LCSW-C, LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LC50077993	DC
2	1041C0700X	Clinical Social Worker	0904009461	VA
3	1041C0700X	Clinical Social Worker	12614	MD

General Provider Information

NPI Number	:	1083988133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHELLE A DILLARD LCSW-C, LICSW

Provider Business Mailing Address
First Line	:	11705 BERRY RD STE 104
Second Line	:
City	:	WALDORF
State	:	MD
Zip	:	20603-5933
Country	:	US
Telephone Number	:	240-207-4513
Fax Number	:	240-846-6037

Provider Business Practice Location Address
First Line	:	11705 BERRY RD STE 104
Second Line	:
City	:	WALDORF
State	:	MD
Zip	:	20603-5933
Country	:	US
Telephone Number	:	140-207-4513
Fax Number	:	240-846-6037

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2012
Last Update Date	:	07/21/2022

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