Basic Information
| Provider Information | |||||||||
| NPI: | 1649585316 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DILL | ||||||||
| FirstName: | MARY ALEX | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LGSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DILL | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | ALEXANDRA | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LGSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 317 HOSPITAL ST | ||||||||
| Address2: | |||||||||
| City: | MOULTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356501269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2569746697 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 295 HOSPITAL ST | ||||||||
| Address2: | |||||||||
| City: | MOULTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356501210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2569746697 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2010 | ||||||||
| LastUpdateDate: | 11/18/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 3021G | AL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.