Provider Demographics
NPI:1124599220
Name:HODGDON, STACEY (BCBA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HODGDON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LEIGH
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:53 PERIMETER CTR E STE 550
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30346-2228
Mailing Address - Country:US
Mailing Address - Phone:770-822-9115
Mailing Address - Fax:770-822-9457
Practice Address - Street 1:53 PERIMETER CTR E STE 550
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30346-2228
Practice Address - Country:US
Practice Address - Phone:770-822-9115
Practice Address - Fax:770-822-9457
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-16-23695103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1-16-23695OtherDEGREE