Provider Demographics
NPI:1073941365
Name:HODGE, CHARLES BRYAN (MNM)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:BRYAN
Last Name:HODGE
Suffix:
Gender:M
Credentials:MNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 NE 20TH AVE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2275
Mailing Address - Country:US
Mailing Address - Phone:503-290-1905
Mailing Address - Fax:503-290-1925
Practice Address - Street 1:825 NE 20TH AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2275
Practice Address - Country:US
Practice Address - Phone:503-290-1905
Practice Address - Fax:503-290-1925
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker