Healthcare Provider Details

I. General information

NPI: 1245924562
Provider Name (Legal Business Name): DAVIS RICHARD DODGE M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10222 WATER WORKS LANE
RIVERVIEW FL
33578
US

IV. Provider business mailing address

10222 WATER WORKS LANE
RIVERVIEW FL
33578
US

V. Phone/Fax

Practice location:
  • Phone: 866-933-0999
  • Fax:
Mailing address:
  • Phone: 866-933-0999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH27715
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: