Provider Demographics
NPI:1346465200
Name:DODGE, ELLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:DODGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 BLOOD ST
Mailing Address - Street 2:
Mailing Address - City:LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-3507
Mailing Address - Country:US
Mailing Address - Phone:860-460-0488
Mailing Address - Fax:
Practice Address - Street 1:186 BLOOD ST
Practice Address - Street 2:
Practice Address - City:LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-3507
Practice Address - Country:US
Practice Address - Phone:860-460-0488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0030781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical