Provider Demographics
NPI:1841623758
Name:DODGE, NOELLE J
Entity type:Individual
Prefix:
First Name:NOELLE
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 1:1845 GRANDSTAND PLACE
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-2052
Mailing Address - Country:US
Mailing Address - Phone:847-695-0484
Mailing Address - Fax:
Practice Address - Street 1:1845 GRANDSTAND PLACE
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-2052
Practice Address - Country:US
Practice Address - Phone:847-695-0484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health