Provider Demographics
NPI:1366952871
Name:DODGE, HEATHER KATHLEEN
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:KATHLEEN
Last Name:DODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BOWMAN ST
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:ME
Mailing Address - Zip Code:04530-2304
Mailing Address - Country:US
Mailing Address - Phone:207-844-4354
Mailing Address - Fax:
Practice Address - Street 1:9 BOWMAN ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:ME
Practice Address - Zip Code:04530-2304
Practice Address - Country:US
Practice Address - Phone:207-844-4354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC168791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical