Healthcare Provider Details

I. General information

NPI: 1487650362
Provider Name (Legal Business Name): MARY CYNTHIA DYGERT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY DYGERT BEAVANS LCSW

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W MARKET ST
COLUMBIA CITY IN
46725-2311
US

IV. Provider business mailing address

850 N HARRISON ST ATTN: ANNE LAWSON
WARSAW IN
46580-3163
US

V. Phone/Fax

Practice location:
  • Phone: 260-248-8176
  • Fax: 260-248-2366
Mailing address:
  • Phone: 574-267-7169
  • Fax: 574-268-2377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34001958A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: