Provider Demographics
NPI:1033231584
Name:HODGENS, TARA A (MS)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:A
Last Name:HODGENS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 S MELROSE DR
Mailing Address - Street 2:APT. 24
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-8781
Mailing Address - Country:US
Mailing Address - Phone:760-597-9471
Mailing Address - Fax:
Practice Address - Street 1:410 S MELROSE DR
Practice Address - Street 2:STE 202
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-6642
Practice Address - Country:US
Practice Address - Phone:610-840-5487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43981106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist