Provider Demographics
NPI:1053660407
Name:LODGE, JOE A (BSW)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:A
Last Name:LODGE
Suffix:
Gender:M
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 N VILLA AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOWS
Mailing Address - State:CA
Mailing Address - Zip Code:95988-2641
Mailing Address - Country:US
Mailing Address - Phone:530-934-6582
Mailing Address - Fax:530-934-6592
Practice Address - Street 1:40 LANDING CIR
Practice Address - Street 2:SUITE 1
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-7901
Practice Address - Country:US
Practice Address - Phone:530-893-3698
Practice Address - Fax:530-893-3748
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAL1209201910101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator