Provider Demographics
NPI:1174737613
Name:DODGE, MATTHEW C (PLMHP)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:C
Last Name:DODGE
Suffix:
Gender:M
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4650
Mailing Address - Country:US
Mailing Address - Phone:308-635-3171
Mailing Address - Fax:308-635-7026
Practice Address - Street 1:4110 AVENUE D
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4650
Practice Address - Country:US
Practice Address - Phone:308-635-3171
Practice Address - Fax:308-635-7026
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-328101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)