Provider Demographics
NPI:1750095600
Name:DODGE, KATIE J
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:J
Last Name:DODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 N 2650 E
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-5509
Mailing Address - Country:US
Mailing Address - Phone:208-520-3204
Mailing Address - Fax:
Practice Address - Street 1:242 E 7TH N STE 4
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-3550
Practice Address - Country:US
Practice Address - Phone:208-359-9683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCOUL-9249101YM0800X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health