MEDICARE: SUSAN MAY DODGE 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

General Provider Information

NPI Number	:	1447992367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN MAY DODGE LICSW

Provider Business Mailing Address
First Line	:	120 74TH AVE N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55444-2699
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 74TH AVE N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55444-2699
Country	:	US
Telephone Number	:	763-458-0706
Fax Number	:

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

Provider Enumeration Date	:	04/11/2022
Last Update Date	:	04/11/2022

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