Provider Demographics
NPI:1295940690
Name:DODGE, CHARLES WILLIAM (PLC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
Last Name:DODGE
Suffix:
Gender:M
Credentials:PLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2921
Mailing Address - Country:US
Mailing Address - Phone:989-723-0330
Mailing Address - Fax:989-723-0327
Practice Address - Street 1:123 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2921
Practice Address - Country:US
Practice Address - Phone:989-723-0330
Practice Address - Fax:989-723-0327
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005935101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1016541Medicaid