Provider Demographics
NPI:1447567458
Name:DODGE, LISA (MA, LLP, CAADC)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:DODGE
Suffix:
Gender:F
Credentials:MA, LLP, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 TRAILSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:WIXOM
Mailing Address - State:MI
Mailing Address - Zip Code:48393-1587
Mailing Address - Country:US
Mailing Address - Phone:248-926-0871
Mailing Address - Fax:
Practice Address - Street 1:23965 NOVI RD STE 130
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-0204
Practice Address - Country:US
Practice Address - Phone:248-946-4664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361007904103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical