Provider Demographics
NPI:1245822113
Name:LODGE, TAHIRA (PHD)
Entity type:Individual
Prefix:DR
First Name:TAHIRA
Middle Name:
Last Name:LODGE
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 1:76 WILLOWWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-4030
Mailing Address - Country:US
Mailing Address - Phone:617-510-5957
Mailing Address - Fax:
Practice Address - Street 1:49 ROBINWOOD AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2156
Practice Address - Country:US
Practice Address - Phone:617-390-1220
Practice Address - Fax:617-390-1595
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7139101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health