Healthcare Provider Details

I. General information

NPI: 1982953014
Provider Name (Legal Business Name): JANETTE ROBINSON DODGE MFT INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANETTE ROBINSON MFT INTERN

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6765 GREEN VALLEY RD
PLACERVILLE CA
95667-8984
US

IV. Provider business mailing address

PO BOX 413
PLACERVILLE CA
95667-0413
US

V. Phone/Fax

Practice location:
  • Phone: 530-622-5551
  • Fax:
Mailing address:
  • Phone: 530-957-1308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number72113
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: