Healthcare Provider Details

I. General information

NPI: 1568559219
Provider Name (Legal Business Name): JOAN M LODGE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 SOUTHTOWNE DR JANET WATTLES CENTER
BELVIDERE IL
61008-5643
US

IV. Provider business mailing address

526 W STATE STREET
ROCKFORD IL
61101-1214
US

V. Phone/Fax

Practice location:
  • Phone: 815-544-4849
  • Fax: 815-544-2116
Mailing address:
  • Phone: 815-968-9300
  • Fax: 815-968-5314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: