Provider Demographics
NPI:1194862128
Name:DODGE, MARGARET A (MED)
Entity Type:Individual
Prefix:MS
First Name:MARGARET
Middle Name:A
Last Name:DODGE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MS
Other - First Name:MARGARET
Other - Middle Name:A
Other - Last Name:NAHLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1417 MAC FARLAND
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-7530
Mailing Address - Country:US
Mailing Address - Phone:907-445-5307
Mailing Address - Fax:907-455-5306
Practice Address - Street 1:1417 MAC FARLAND
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-7530
Practice Address - Country:US
Practice Address - Phone:907-479-0245
Practice Address - Fax:907-479-0245
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLCPC724101Y00000X
AK562101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
000009153Medicare UPIN