Provider Demographics
NPI:1598811218
Name:DODGE, DIANE
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name: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 1:3923 E SHANGRI LA RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-2820
Mailing Address - Country:US
Mailing Address - Phone:602-622-0374
Mailing Address - Fax:
Practice Address - Street 1:8801 N 56TH ST
Practice Address - Street 2:CHEROKEE ELEMENTARY SCHOOL
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-2246
Practice Address - Country:US
Practice Address - Phone:480-484-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0009235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ629131OtherARIZONA HEALTH CARE COST