Provider Demographics
NPI:1841727732
Name:DODGE, MICHELLE LYNEA (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNEA
Last Name:DODGE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 SAN PABLO RD S APT 303
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-2091
Mailing Address - Country:US
Mailing Address - Phone:616-443-1642
Mailing Address - Fax:
Practice Address - Street 1:1851 GOLDEN EAGLE WAY STE 43
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4334
Practice Address - Country:US
Practice Address - Phone:904-626-7922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14102758235Z00000X
FLSA14928235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist