Provider Demographics
NPI:1548476419
Name:DODSON, BONNY LU (LCSW)
Entity type:Individual
Prefix:MRS
First Name:BONNY
Middle Name:LU
Last Name:DODSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ABBOTT LN
Mailing Address - Street 2:
Mailing Address - City:ETNA
Mailing Address - State:ME
Mailing Address - Zip Code:04434-3041
Mailing Address - Country:US
Mailing Address - Phone:207-269-2703
Mailing Address - Fax:207-990-3896
Practice Address - Street 1:40 SUMMER ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6446
Practice Address - Country:US
Practice Address - Phone:207-947-0366
Practice Address - Fax:207-990-3896
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC41421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM5400Medicare ID - Type Unspecified