Provider Demographics
NPI:1922644160
Name:DODDS, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:DODDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:781 OSPREY LN
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-4170
Mailing Address - Country:US
Mailing Address - Phone:520-227-4994
Mailing Address - Fax:
Practice Address - Street 1:1135 WALTONS PASS
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-8250
Practice Address - Country:US
Practice Address - Phone:706-755-2785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-19-96174106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician