Provider Demographics
NPI:1639421449
Name:LODGE, JOHN KENNETH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KENNETH
Last Name:LODGE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3171 BEAVER VU DR STE B
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-6368
Mailing Address - Country:US
Mailing Address - Phone:937-431-8014
Mailing Address - Fax:937-431-8042
Practice Address - Street 1:3171 BEAVER VU DR STE B
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45434-6368
Practice Address - Country:US
Practice Address - Phone:937-431-8014
Practice Address - Fax:937-431-8042
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7194103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist