Healthcare Provider Details

I. General information

NPI: 1639114663
Provider Name (Legal Business Name): RICHARD LORNAL DODGE PHD CADCII ICRE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DICK DODGE PHD

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 11/02/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3407 SHAMROCK CT
GAUTIER MS
39553
US

IV. Provider business mailing address

3407 SHAMPROCK CT
GAUTIER MS
39553
US

V. Phone/Fax

Practice location:
  • Phone: 228-497-0690
  • Fax: 228-497-1363
Mailing address:
  • Phone: 228-497-0690
  • Fax: 228-497-1363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA8424202
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: