Provider Demographics
NPI:1003116351
Name:DODGE, PETER (LMSW)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:DODGE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 W STATE ST
Mailing Address - Street 2:PO BOX 789
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5432
Mailing Address - Country:US
Mailing Address - Phone:607-273-5500
Mailing Address - Fax:607-273-1277
Practice Address - Street 1:334 W STATE ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5432
Practice Address - Country:US
Practice Address - Phone:607-273-5500
Practice Address - Fax:607-273-1277
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NY077988104100000X
NY261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder