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RICHARD LORNAL DODGE PHD CADCII ICRE

Addiction Substance Use Disorder

Gautier, Mississippi

Provider NPI: 1639114663

Provider Information:
 RICHARD LORNAL DODGE PHD CADCII ICRE
Gender: M
Not Sole Proprietor

Practice Location:
3407 SHAMROCK CT  GAUTIER, MS 39553 US
Tel: 228-497-0690  Fax: 228-497-1363

Business Mailing Address:
3407 SHAMPROCK CT  GAUTIER, MS 39553 US
Tel: 228-497-0690  Fax: 228-497-1363

Entity Type: Individual

Taxonomy:

PrimaryCodeCategory/DescriptionStateLicense Number
Y101YA0400XBehavioral Health & Social Service Providers
Counselor
Addiction (Substance Use Disorder)
CAA8424202

Other Provider Identifiers:

IssuerNumberStateType
00018214MS05
Code values:
01, Other | 02, Medicare Upin | 04, Medicare Id-Type Unspecified
05, Medicaid | 06, Medicare Oscar/Certification | 07, Medicare NSC | 08, Medicare Pin







ADDICTION JOBS MS - Page 1



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