Provider Demographics
NPI:1063996486
Name:DODGE, DEBRA LEE
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:LEE
Last Name:DODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 PAKACHOAG ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01501-2425
Mailing Address - Country:US
Mailing Address - Phone:508-517-1058
Mailing Address - Fax:
Practice Address - Street 1:88 SUMMER ST
Practice Address - Street 2:
Practice Address - City:MEDWAY
Practice Address - State:MA
Practice Address - Zip Code:02053-2383
Practice Address - Country:US
Practice Address - Phone:508-533-6643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1145611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA22Medicaid