Provider Demographics
NPI:1255668919
Name:DODSON, ELAINE M (CADC/LMS)
Entity Type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:M
Last Name:DODSON
Suffix:
Gender:F
Credentials:CADC/LMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-415-0299
Mailing Address - Fax:208-625-2070
Practice Address - Street 1:2205 IRONWOOD PL
Practice Address - Street 2:STE A/B
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2785
Practice Address - Country:US
Practice Address - Phone:208-664-8347
Practice Address - Fax:208-664-9217
Is Sole Proprietor?:No
Enumeration Date:2009-11-17
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCANC-118030101YA0400X
IDLSW-27634104100000X
ID27634104100000X
ID11445101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA21113097Medicaid