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General NPI Number Information
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NPI Number | 1962701755
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Entity Type | Organization
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Legal Business Name | DODGE PSYCHOLOGY PRACTICE, LLC
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Dates
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Enumeration Date | 03/20/2011
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Last Update Date | 09/05/2012
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Provider Practice Location Address
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Address Line | 18975 W 115TH TER
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City | OLATHE
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State | KS
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Zip | 66061-6542
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Country | US
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Telephone | 913-232-6861
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Fax |
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Provider Business Mailing Address
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Address Line | 18975 W 115TH TER
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City | OLATHE
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State | KS
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Zip | 66061-6542
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Country | US
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Telephone | 913-232-6861
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. TIMOTHY D DODGE
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Credential | PH.D.
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Telephone | 913-232-6861
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2002011102
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License Number State | MO
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