Provider Demographics
NPI:1104041748
Name:DODGE, ANGELEEN (SLP)
Entity Type:Individual
Prefix:
First Name:ANGELEEN
Middle Name:
Last Name:DODGE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-1943
Mailing Address - Country:US
Mailing Address - Phone:920-929-8858
Mailing Address - Fax:920-923-3038
Practice Address - Street 1:500 N PARK AVE
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-1943
Practice Address - Country:US
Practice Address - Phone:920-929-8858
Practice Address - Fax:920-923-3038
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1962-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42773400Medicaid