Provider Demographics
NPI:1164767471
Name:DODGE, THOMAS M (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:DODGE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1881 WORCESTER RD STE 203
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01701-5410
Mailing Address - Country:US
Mailing Address - Phone:508-834-3183
Mailing Address - Fax:
Practice Address - Street 1:1881 WORCESTER RD STE 203
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01701-5410
Practice Address - Country:US
Practice Address - Phone:508-834-3183
Practice Address - Fax:508-532-1168
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2351706163WP0808X, 364SP0810X
MA17972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Family
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer