Healthcare Provider Details

I. General information

NPI: 1225546674
Provider Name (Legal Business Name): AMY K DODGE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2018
Last Update Date: 10/10/2020
Certification Date: 10/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 CORPORATE DR
HOUMA LA
70360-2769
US

IV. Provider business mailing address

311 RAVENSAIDE DR
HOUMA LA
70360-8369
US

V. Phone/Fax

Practice location:
  • Phone: 508-494-1473
  • Fax:
Mailing address:
  • Phone: 985-873-8586
  • Fax: 985-873-8565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLA7340
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: