Provider Demographics
NPI:1124457916
Name:DODGE, TERRA
Entity type:Individual
Prefix:MS
First Name:TERRA
Middle Name:
Last Name:DODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 W OLIVE AVE # B
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-2214
Mailing Address - Country:US
Mailing Address - Phone:818-848-9995
Mailing Address - Fax:
Practice Address - Street 1:1130 W OLIVE AVE # B
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-2214
Practice Address - Country:US
Practice Address - Phone:818-848-9995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator