MEDICARE: SUSAN SHIRING DODGE LCSW

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	101YP2500X	Professional Counselor	21865	TX

General Provider Information

NPI Number	:	1609888387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN SHIRING DODGE LCSW

Provider Business Mailing Address
First Line	:	PO BOX 638
Second Line	:
City	:	QUITMAN
State	:	TX
Zip	:	75783-0638
Country	:	US
Telephone Number	:	214-808-1543
Fax Number	:

Provider Business Practice Location Address
First Line	:	4925 GREENVILLE AVE STE 1125
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75206-0501
Country	:	US
Telephone Number	:	972-918-0170
Fax Number	:

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

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	01/26/2022

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