Provider Demographics
NPI:1710266424
Name:DODGE, ANNA W (AUD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:W
Last Name:DODGE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1595 SOQUEL DRIVE
Mailing Address - Street 2:230
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95065
Mailing Address - Country:US
Mailing Address - Phone:831-476-4414
Mailing Address - Fax:
Practice Address - Street 1:1595 SOQUEL DR
Practice Address - Street 2:230
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1719
Practice Address - Country:US
Practice Address - Phone:831-476-4414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU2791231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU2791OtherSPEECH LANGUAGE PATHOLOGY AND AUDIOLOGY BOARD