Provider Demographics
NPI:1740512284
Name:DODGE, PERRY (LPC)
Entity type:Individual
Prefix:MR
First Name:PERRY
Middle Name:
Last Name:DODGE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 CENTRE POINTE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63304-8579
Mailing Address - Country:US
Mailing Address - Phone:314-814-4111
Mailing Address - Fax:636-928-3524
Practice Address - Street 1:91 CENTRE POINTE DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63304-8579
Practice Address - Country:US
Practice Address - Phone:314-814-4111
Practice Address - Fax:636-928-3524
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005038693101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional