Provider Demographics
NPI:1992128706
Name:LODGE, MICHAEL JR (MSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LODGE
Suffix:JR
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 FAIRMOUNT ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-4602
Mailing Address - Country:US
Mailing Address - Phone:617-669-5589
Mailing Address - Fax:
Practice Address - Street 1:34 FAIRMOUNT ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-4602
Practice Address - Country:US
Practice Address - Phone:617-669-5589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical