Provider Demographics
NPI:1598926362
Name:DODGE, TIMOTHY DEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DEAN
Last Name:DODGE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18975 W 115TH TER
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-6542
Mailing Address - Country:US
Mailing Address - Phone:913-232-6861
Mailing Address - Fax:
Practice Address - Street 1:18975 W 115TH TER
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-6542
Practice Address - Country:US
Practice Address - Phone:913-232-6861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002011102103T00000X
KS1256103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493776314Medicaid