MEDICARE: RYAN DODGE M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1659410538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN DODGE M.S.

Provider Business Mailing Address
First Line	:	7891 BRADY CREEK CV
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38016-8835
Country	:	US
Telephone Number	:	901-624-2834
Fax Number	:

Provider Business Practice Location Address
First Line	:	7426 MEMPHIS ARLINGTON RD
Second Line	:
City	:	BARTLETT
State	:	TN
Zip	:	38135-1908
Country	:	US
Telephone Number	:	901-252-7794
Fax Number	:	901-252-7990

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	07/08/2007

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