Provider Demographics
NPI:1164136610
Name:HODGES, TERESA ELLEN LAVONNE
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ELLEN LAVONNE
Last Name:HODGES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 E SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5873
Mailing Address - Country:US
Mailing Address - Phone:208-620-5222
Mailing Address - Fax:208-292-6660
Practice Address - Street 1:1809 E SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5873
Practice Address - Country:US
Practice Address - Phone:208-620-5222
Practice Address - Fax:208-292-6660
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101YP2500X
IDSE-203699101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional