Provider Demographics
NPI:1952403461
Name:DODSON, DONALD G (PHD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:G
Last Name:DODSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13568 SE 97TH AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6670
Mailing Address - Country:US
Mailing Address - Phone:503-654-1717
Mailing Address - Fax:503-317-2901
Practice Address - Street 1:13568 SE 97TH AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6670
Practice Address - Country:US
Practice Address - Phone:503-654-1717
Practice Address - Fax:503-317-2901
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1366103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR110140Medicare ID - Type Unspecified