Provider Demographics
NPI:1396502720
Name:DODGE, MARISSA (LADC, CCS)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:DODGE
Suffix:
Gender:F
Credentials:LADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SUNDERLAND RD
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04274-7500
Mailing Address - Country:US
Mailing Address - Phone:207-522-9608
Mailing Address - Fax:
Practice Address - Street 1:9 SUNDERLAND RD
Practice Address - Street 2:
Practice Address - City:POLAND
Practice Address - State:ME
Practice Address - Zip Code:04274-7500
Practice Address - Country:US
Practice Address - Phone:207-522-9608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC7702101YA0400X
MECCS8524101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)