Provider Demographics
NPI:1093030447
Name:DODGE, AMANDA (BCABA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DODGE
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:DZIEDZIAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCABA
Mailing Address - Street 1:PO BOX 51322
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-5622
Mailing Address - Country:US
Mailing Address - Phone:270-777-9283
Mailing Address - Fax:270-777-9283
Practice Address - Street 1:2580 LIN DO CT
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1832
Practice Address - Country:US
Practice Address - Phone:803-905-4427
Practice Address - Fax:803-905-4431
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0093641103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst