Provider Demographics
NPI:1821543000
Name:DODGE, JUSTINA KELSEY (LCSW)
Entity Type:Individual
Prefix:
First Name:JUSTINA
Middle Name:KELSEY
Last Name:DODGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JUSTINA
Other - Middle Name:KELSEY
Other - Last Name:HAGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:725 WEST CENTRAL AVENUE #208
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6800
Mailing Address - Country:US
Mailing Address - Phone:406-926-1231
Mailing Address - Fax:406-926-1231
Practice Address - Street 1:725 WEST CENTRAL AVE
Practice Address - Street 2:#208
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6800
Practice Address - Country:US
Practice Address - Phone:406-926-1231
Practice Address - Fax:406-926-1231
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT181861041C0700X
MTBBH-LCSW-LIC-181861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical