Provider Demographics
NPI:1568006161
Name:DODGE, JUSTINE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:DODGE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 PRUITT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87547-3627
Mailing Address - Country:US
Mailing Address - Phone:505-933-4336
Mailing Address - Fax:
Practice Address - Street 1:402 PRUITT AVE
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87547-3627
Practice Address - Country:US
Practice Address - Phone:505-933-4336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5085235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist