Provider Demographics
NPI:1437842374
Name:HILLIARD-DODGE, KAE MARIE
Entity Type:Individual
Prefix:
First Name:KAE
Middle Name:MARIE
Last Name:HILLIARD-DODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 SOUTHVIEW AVE # 4
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-5081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:875 PERIMETER DR
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83844-9803
Practice Address - Country:US
Practice Address - Phone:208-855-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistGroup - Multi-Specialty