Provider Demographics
NPI:1063487189
Name:DODGE, AMANDA MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIE
Last Name:DODGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 MAIN ST
Mailing Address - Street 2:NORTHBOROUGH MEDICAL BUILDING
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 MAIN ST
Practice Address - Street 2:HARDY PHYSICAL THERAPY REHABILITATIONS SERVICES INC
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532
Practice Address - Country:US
Practice Address - Phone:508-393-7298
Practice Address - Fax:508-393-1338
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
468920OtherTUFTS
Y68332OtherBCBS
Y69269Medicare ID - Type Unspecified