Provider Demographics
NPI:1942289152
Name:DODGE, KENNETH L (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:DODGE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 WATER ST
Mailing Address - Street 2:# 323
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-4779
Mailing Address - Country:US
Mailing Address - Phone:515-244-2541
Mailing Address - Fax:
Practice Address - Street 1:3600 LINCOLN WAY
Practice Address - Street 2:SUITE 4
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50014-7595
Practice Address - Country:US
Practice Address - Phone:515-239-4410
Practice Address - Fax:515-663-4885
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00873103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA33402OtherBLUE SHIELD OF IOWA
IA33402OtherBLUE SHIELD OF IOWA
IAS86295Medicare UPIN