Provider Demographics
NPI:1053644328
Name:HODGES, THERESA LEA (CADC)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:LEA
Last Name:HODGES
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13192 BRUNSWICK RD
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-9388
Mailing Address - Country:US
Mailing Address - Phone:530-273-0631
Mailing Address - Fax:530-504-4328
Practice Address - Street 1:13192 BRUNSWICK RD
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9388
Practice Address - Country:US
Practice Address - Phone:530-273-0631
Practice Address - Fax:530-504-4328
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC19661214101YM0800X
CAMPSS-RJOFHE175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6906OtherCAARR