Healthcare Provider Details

I. General information

NPI: 1689311797
Provider Name (Legal Business Name): EDRIS F LODGE PSYD, LPCT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DR. EDRIS F LODGE

II. Dates (important events)

Enumeration Date: 05/19/2022
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5049 MELROSE BLVD STE 1
BATON ROUGE LA
70806-3515
US

IV. Provider business mailing address

12171 CANTERBURY PARK DR
GEISMAR LA
70734-3270
US

V. Phone/Fax

Practice location:
  • Phone: 225-933-5553
  • Fax:
Mailing address:
  • Phone: 225-933-5553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberEL860039
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: