Basic Information
| Provider Information | |||||||||
| NPI: | 1194862128 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DODGE | ||||||||
| FirstName: | MARGARET | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MED | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NAHLEN | ||||||||
| OtherFirstName: | MARGARET | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1417 MAC FARLAND | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997097530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074455307 | ||||||||
| FaxNumber: | 9074555306 | ||||||||
| Practice Location | |||||||||
| Address1: | 1417 MAC FARLAND | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997097530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074790245 | ||||||||
| FaxNumber: | 9074790245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 08/30/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | LCPC724 | MT | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 562 | AK | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.