Provider Demographics
NPI:1942845086
Name:DODGE, KATHLEEN (LADC II)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:DODGE
Suffix:
Gender:F
Credentials:LADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HAVERHILL RD STE 206
Mailing Address - Street 2:
Mailing Address - City:AMESBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01913-2123
Mailing Address - Country:US
Mailing Address - Phone:978-834-6583
Mailing Address - Fax:978-462-0735
Practice Address - Street 1:110 HAVERHILL RD STE 206
Practice Address - Street 2:
Practice Address - City:AMESBURY
Practice Address - State:MA
Practice Address - Zip Code:01913-2123
Practice Address - Country:US
Practice Address - Phone:978-834-6583
Practice Address - Fax:978-462-0735
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18541101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)