Healthcare Provider Details

I. General information

NPI: 1306258595
Provider Name (Legal Business Name): KATHLEEN MARIE DODGE MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 ARROYO DRIVE
PACIFICA CA
94044
US

IV. Provider business mailing address

243 ARROYO DR
PACIFICA CA
94044-2302
US

V. Phone/Fax

Practice location:
  • Phone: 650-278-7524
  • Fax:
Mailing address:
  • Phone: 650-278-7524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF 66263
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: