Provider Demographics
NPI:1639114663
Name:DODGE, RICHARD LORNAL (PHD CADCII ICRE)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LORNAL
Last Name:DODGE
Suffix:
Gender:M
Credentials:PHD CADCII ICRE
Other - Prefix:
Other - First Name:DICK
Other - Middle Name:
Other - Last Name:DODGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:3407 SHAMPROCK CT
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553
Mailing Address - Country:US
Mailing Address - Phone:228-497-0690
Mailing Address - Fax:228-497-1363
Practice Address - Street 1:3407 SHAMROCK CT
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553
Practice Address - Country:US
Practice Address - Phone:228-497-0690
Practice Address - Fax:228-497-1363
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA8424202101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid