Provider Demographics
NPI:1720700404
Name:LODGE, ALEXANDER (MA)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:LODGE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 METCALF DR
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-8802
Mailing Address - Country:US
Mailing Address - Phone:802-503-2929
Mailing Address - Fax:
Practice Address - Street 1:75 TALCOTT RD STE 30
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-8122
Practice Address - Country:US
Practice Address - Phone:802-503-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047.0133699101YM0800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health