Provider Demographics
NPI:1376587428
Name:DODGE, KRISTIE ANN (OTR/L)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:ANN
Last Name:DODGE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E MICHIGAN AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1406
Mailing Address - Country:US
Mailing Address - Phone:902-308-4801
Mailing Address - Fax:
Practice Address - Street 1:340 N MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2620
Practice Address - Country:US
Practice Address - Phone:928-771-0465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2976225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist