Provider Demographics
NPI:1073060661
Name:DODGE, LAURA S
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:S
Last Name:DODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 RETREAT AVENUE
Mailing Address - Street 2:HARTFORD HOSPITAL PSYCHIATRY DEPT.
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3310
Mailing Address - Country:US
Mailing Address - Phone:860-545-7200
Mailing Address - Fax:
Practice Address - Street 1:200 RETREAT AVENUE
Practice Address - Street 2:HARTFORD HOSPITAL PSYCHIATRY DEPT.
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3310
Practice Address - Country:US
Practice Address - Phone:860-545-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0063811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical