Provider Demographics
NPI:1013559657
Name:HODGE, LAUREN (ATC)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:HODGE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 NEW STATE RD APT 7
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-7941
Mailing Address - Country:US
Mailing Address - Phone:860-638-9700
Mailing Address - Fax:
Practice Address - Street 1:12 MAIN ST STE 7
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06029-3361
Practice Address - Country:US
Practice Address - Phone:860-872-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0012432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer