Basic Information
| Provider Information | |||||||||
| NPI: | 1811638737 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DODSON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | SAMUEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DODSON | ||||||||
| OtherFirstName: | TOM | ||||||||
| OtherMiddleName: | SAMUEL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2911 W UINTAH ST APT 1 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809042487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025907000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3141 CENTENNIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809074094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193275660 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2022 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QV0200X | PSY.0005768 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | VA |
No ID Information.