Provider Demographics
NPI:1689311797
Name:LODGE, EDRIS F (PSYD, LPCT)
Entity Type:Individual
Prefix:
First Name:EDRIS
Middle Name:F
Last Name:LODGE
Suffix:
Gender:F
Credentials:PSYD, LPCT
Other - Prefix:DR
Other - First Name:EDRIS
Other - Middle Name:F
Other - Last Name:LODGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:12171 CANTERBURY PARK DR
Mailing Address - Street 2:
Mailing Address - City:GEISMAR
Mailing Address - State:LA
Mailing Address - Zip Code:70734-3270
Mailing Address - Country:US
Mailing Address - Phone:225-933-5553
Mailing Address - Fax:
Practice Address - Street 1:5049 MELROSE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-3515
Practice Address - Country:US
Practice Address - Phone:225-933-5553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-19
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LAEL860039103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No171M00000XOther Service ProvidersCase Manager/Care Coordinator