=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780881474
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BAYARD DODGE REA PSY.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2007
-----------------------------------------------------
Last Update Date | 07/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2919 BERRY HILL DR
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37204-3126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-577-0995
-----------------------------------------------------
Fax | 614-577-0997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2919 BERRY HILL DR
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37204-3126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-577-0995
-----------------------------------------------------
Fax | 614-577-0997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 0000002482
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TF0000X
-----------------------------------------------------
Taxonomy Name | Family Psychologist
-----------------------------------------------------
License Number | 0000002482
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TP2701X
-----------------------------------------------------
Taxonomy Name | Group Psychotherapy Psychologist
-----------------------------------------------------
License Number | 0000002482
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------