=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932537859
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VALERIE DODGE MPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2013
-----------------------------------------------------
Last Update Date | 11/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 244 W 54TH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10019-5515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-262-7246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2712 KIPLING ST
-----------------------------------------------------
City | PALO ALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94306-2427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 036383-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------