Provider Demographics
NPI:1912304775
Name:DODGE, DAMON (LMFT 99912)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:
Last Name:DODGE
Suffix:
Gender:M
Credentials:LMFT 99912
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7083 HOLLYWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-8901
Mailing Address - Country:US
Mailing Address - Phone:323-332-1325
Mailing Address - Fax:
Practice Address - Street 1:7083 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028
Practice Address - Country:US
Practice Address - Phone:323-332-1325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-21
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99912106H00000X, 106H00000X
CA87840106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01536011OtherMEDI-CAL