Provider Demographics
NPI:1578860466
Name:REBECCA DODGE, PH.D.
Entity Type:Organization
Organization Name:REBECCA DODGE, PH.D.
Other - Org Name:ACADEMIC THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:209-532-5132
Mailing Address - Street 1:145 S WASHINGTON ST STE H-2
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-4722
Mailing Address - Country:US
Mailing Address - Phone:209-532-5132
Mailing Address - Fax:209-532-1348
Practice Address - Street 1:145 S WASHINGTON ST STE H-2
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-4722
Practice Address - Country:US
Practice Address - Phone:209-532-5132
Practice Address - Fax:209-532-1348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-11
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2520251C00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0513639Medicaid