Provider Demographics
NPI:1568800845
Name:DODGE, JANICE PATRICE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JANICE
Middle Name:PATRICE
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:PO BOX 38365
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-1006
Mailing Address - Country:US
Mailing Address - Phone:704-996-8794
Mailing Address - Fax:
Practice Address - Street 1:245 E MAIN AVE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-4142
Practice Address - Country:US
Practice Address - Phone:704-996-8794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3560103TB0200X, 103TC0700X, 103TF0000X, 103TF0200X, 103TM1800X, 103TP0814X, 103TP2701X
CAPSY 14729103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy