Provider Demographics
NPI:1831865955
Name:DODGE, KATHLEEN LICATA
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LICATA
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 1:67 CROCKER AVE
Mailing Address - Street 2:
Mailing Address - City:TURNERS FALLS
Mailing Address - State:MA
Mailing Address - Zip Code:01376-1925
Mailing Address - Country:US
Mailing Address - Phone:413-388-1952
Mailing Address - Fax:
Practice Address - Street 1:67 CROCKER AVE
Practice Address - Street 2:
Practice Address - City:TURNERS FALLS
Practice Address - State:MA
Practice Address - Zip Code:01376-1925
Practice Address - Country:US
Practice Address - Phone:413-388-1952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN191969163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)