Healthcare Provider Details

I. General information

NPI: 1003116351
Provider Name (Legal Business Name): PETER DODGE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 W STATE ST
ITHACA NY
14850-5432
US

IV. Provider business mailing address

334 W STATE ST PO BOX 789
ITHACA NY
14850-5432
US

V. Phone/Fax

Practice location:
  • Phone: 607-273-5500
  • Fax: 607-273-1277
Mailing address:
  • Phone: 607-273-5500
  • Fax: 607-273-1277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number077988
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: