Provider Demographics
NPI:1689746653
Name:DODGE, CYNTHIA A (PHD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:A
Last Name:DODGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 COLINAS
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86351-9238
Mailing Address - Country:US
Mailing Address - Phone:928-853-8269
Mailing Address - Fax:
Practice Address - Street 1:25827 N 122ND LN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-5814
Practice Address - Country:US
Practice Address - Phone:928-863-8431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC4083103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME194420299Medicaid
MERB9OtherANTHEM