Provider Demographics
NPI:1396468138
Name:DODGE, MICHELLE MARIE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:DODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:EHRLICHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:690 CLEVELAND AVE S STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1319
Mailing Address - Country:US
Mailing Address - Phone:651-493-8412
Mailing Address - Fax:
Practice Address - Street 1:690 CLEVELAND AVE S STE 100
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1319
Practice Address - Country:US
Practice Address - Phone:651-493-8412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician