Provider Demographics
NPI:1194917831
Name:MASTRUD, DOROTHY MAE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:MAE
Last Name:MASTRUD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DOROTHY
Other - Middle Name:MAE
Other - Last Name:SUCKERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:509 25TH AVE NORTH
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102
Mailing Address - Country:US
Mailing Address - Phone:701-232-6224
Mailing Address - Fax:
Practice Address - Street 1:509 25TH AVE NORTH
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102
Practice Address - Country:US
Practice Address - Phone:701-232-6224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2442104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker