Provider Demographics
NPI:1437285897
Name:DIXIE H DODGE PHD PC
Entity Type:Organization
Organization Name:DIXIE H DODGE PHD PC
Other - Org Name:DIXIE H DODGE PHD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIXIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD PSYCHOLOGY
Authorized Official - Phone:719-636-2669
Mailing Address - Street 1:219 EAST ST VRAIN
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903
Mailing Address - Country:US
Mailing Address - Phone:719-636-2669
Mailing Address - Fax:719-577-9656
Practice Address - Street 1:219 EAST ST VRAIN
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903
Practice Address - Country:US
Practice Address - Phone:719-636-2669
Practice Address - Fax:719-577-9656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1171103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO034211OtherMEDICADE
80206OtherBLUE CROSS
35197OtherANTHEM
10412365OtherCAQH
80206OtherBLUE CROSS