Provider Demographics
NPI:1205167160
Name:DODGE, REBECCA M (PSYD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:M
Last Name:DODGE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 NE HANCOCK ST # 316
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-5321
Mailing Address - Country:US
Mailing Address - Phone:971-808-2547
Mailing Address - Fax:503-288-7877
Practice Address - Street 1:3939 NE HANCOCK ST # 316
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-5321
Practice Address - Country:US
Practice Address - Phone:971-808-2547
Practice Address - Fax:503-288-7877
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2475103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical