Provider Demographics
NPI:1407116726
Name:BETH DODGE, INC.
Entity Type:Organization
Organization Name:BETH DODGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:773-633-9662
Mailing Address - Street 1:223 S CUYLER AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3301
Mailing Address - Country:US
Mailing Address - Phone:773-633-9662
Mailing Address - Fax:
Practice Address - Street 1:820 NORTH BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1351
Practice Address - Country:US
Practice Address - Phone:708-524-2445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.002463225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty