Provider Demographics
NPI:1134284037
Name:DODGE, DAVID (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:DODGE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 S MAIN ST
Mailing Address - Street 2:OFFICE #3, 2ND FLOOR
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-3512
Mailing Address - Country:US
Mailing Address - Phone:845-639-5061
Mailing Address - Fax:
Practice Address - Street 1:39 S MAIN ST
Practice Address - Street 2:OFFICE #3, 2ND FLOOR
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-3512
Practice Address - Country:US
Practice Address - Phone:845-639-5061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR044095-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical