Provider Demographics
NPI:1659410538
Name:DODGE, RYAN (MS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DODGE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7891 BRADY CREEK CV
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-8835
Mailing Address - Country:US
Mailing Address - Phone:901-624-2834
Mailing Address - Fax:
Practice Address - Street 1:7426 MEMPHIS ARLINGTON RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38135-1908
Practice Address - Country:US
Practice Address - Phone:901-252-7794
Practice Address - Fax:901-252-7990
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health