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 1:10164 SUDBERRY DR
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9576
Mailing Address - Country:US
Mailing Address - Phone:724-284-4275
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001-4670
Practice Address - Country:US
Practice Address - Phone:724-284-4275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA25 400 761101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)