Provider Demographics
NPI:1942569629
Name:DODGE, STEPHANIE ANN (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:DODGE
Suffix:
Gender:F
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:PO BOX 11339
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96721
Mailing Address - Country:US
Mailing Address - Phone:808-747-3445
Mailing Address - Fax:
Practice Address - Street 1:56 WAIANUENUE AVENUE
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720
Practice Address - Country:US
Practice Address - Phone:808-747-3445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY1318103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000000000OtherI DON'T HAVE ANOTHER IDENTIFICATION NUMBER