Provider Demographics
NPI:1932134442
Name:DODSON, TINA R (LPN / LPC)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:R
Last Name:DODSON
Suffix:
Gender:F
Credentials:LPN / LPC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9565
Mailing Address - Street 2:POB 9565 / 5813 LAUREL AVE / T.DODSON, LPN / LPC
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133-0365
Mailing Address - Country:US
Mailing Address - Phone:816-550-9549
Mailing Address - Fax:816-313-6907
Practice Address - Street 1:5813 LAUREL AVE
Practice Address - Street 2:C/O POB 9565 / 5813 LAUREL AVE / T.DODSON, LPN / LPC
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-3260
Practice Address - Country:US
Practice Address - Phone:816-550-9549
Practice Address - Fax:816-313-6907
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001004045101YP2500X
MO032173164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered164W00000XNursing Service ProvidersLicensed Practical Nurse