Provider Demographics
NPI:1659442929
Name:DODGE, CHERYL R (PT)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:R
Last Name:DODGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2044 SW MOCKINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-2418
Mailing Address - Country:US
Mailing Address - Phone:772-220-1009
Mailing Address - Fax:
Practice Address - Street 1:702 NE JENSEN BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-4752
Practice Address - Country:US
Practice Address - Phone:772-225-8908
Practice Address - Fax:772-225-0843
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10645225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist