MEDICARE: MS. MIA S DORMAN LCSW CADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	1052	DE
2	1041C0700X	Clinical Social Worker	Q1-0001689	DE

General Provider Information

NPI Number	:	1437481488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MIA S DORMAN LCSW CADC

Provider Business Mailing Address
First Line	:	404 STERLING AVE
Second Line	:
City	:	NEW CASTLE
State	:	DE
Zip	:	19720-4777
Country	:	US
Telephone Number	:	302-650-4289
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 POSSUM PARK RD STE 5
Second Line	:
City	:	NEWARK
State	:	DE
Zip	:	19711-3831
Country	:	US
Telephone Number	:	302-444-4796
Fax Number	:	302-444-4727

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

Provider Enumeration Date	:	02/02/2010
Last Update Date	:	08/01/2019

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