Provider Demographics
NPI:1376817577
Name:DODGE, CYNTHIA SUE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:SUE
Last Name:DODGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2579 THATCHER AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-6916
Mailing Address - Country:US
Mailing Address - Phone:510-965-8394
Mailing Address - Fax:
Practice Address - Street 1:2579 THATCHER AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-6916
Practice Address - Country:US
Practice Address - Phone:510-965-8394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK393103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist