Provider Demographics
NPI:1104084714
Name:LODGE, KEITH (MSED)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:LODGE
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 N DUFFY RD
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:PA
Mailing Address - Zip Code:16001-1138
Mailing Address - Country:US
Mailing Address - Phone:878-271-6546
Mailing Address - Fax:
Practice Address - Street 1:353 N DUFFY RD
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001-1138
Practice Address - Country:US
Practice Address - Phone:878-271-6546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2025-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005906101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)