Provider Demographics
NPI:1992206080
Name:DODGE, WILLIAM PAUL (LSW)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:PAUL
Last Name:DODGE
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5440 LAKEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-9513
Mailing Address - Country:US
Mailing Address - Phone:330-979-7798
Mailing Address - Fax:
Practice Address - Street 1:275 MARTINEL DR
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-4380
Practice Address - Country:US
Practice Address - Phone:330-673-6446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.00252621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical