Provider Demographics
NPI:1922256809
Name:DODGE, SEAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:
Last Name:DODGE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 NE 3RD ST STE 1061019
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3894
Mailing Address - Country:US
Mailing Address - Phone:775-297-8855
Mailing Address - Fax:
Practice Address - Street 1:211 NW LARCH AVE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1357
Practice Address - Country:US
Practice Address - Phone:541-548-2164
Practice Address - Fax:541-548-0534
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY0624103TC0700X
OR2871103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical