Provider Demographics
NPI:1881739241
Name:DODGE, LAURA J TRIPET
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:J TRIPET
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 1:4601 EXCELSIOR BLVD
Mailing Address - Street 2:SUITE 501A
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416
Mailing Address - Country:US
Mailing Address - Phone:952-933-3121
Mailing Address - Fax:952-933-3511
Practice Address - Street 1:4601 EXCELSIOR BLVD
Practice Address - Street 2:SUITE 501A
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416
Practice Address - Country:US
Practice Address - Phone:952-933-3121
Practice Address - Fax:952-933-3511
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1396103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN079N9TROtherBCBS
MN975348600Medicaid