Provider Demographics
NPI:1033326699
Name:DODGE, REBECCA ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:ANN
Last Name:DODGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 SOUTH STEWARD STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-4771
Mailing Address - Country:US
Mailing Address - Phone:209-532-5132
Mailing Address - Fax:209-532-1348
Practice Address - Street 1:86 SOUTH STEWARD STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-4771
Practice Address - Country:US
Practice Address - Phone:209-532-5132
Practice Address - Fax:209-532-1348
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2520103TC1900X, 103TE1100X, 103TF0000X, 103TM1800X, 103TS0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool