Provider Demographics
NPI:1164486536
Name:HODGE, MARY BETH (OT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:HODGE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 FORT SANDERS WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3355
Mailing Address - Country:US
Mailing Address - Phone:865-769-4545
Mailing Address - Fax:865-769-4501
Practice Address - Street 1:260 FORT SANDERS WEST BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3355
Practice Address - Country:US
Practice Address - Phone:865-558-4491
Practice Address - Fax:865-558-4493
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1807225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4111080OtherBLUE CROSS BLUE SHIELD
TN3645932Medicaid
TN3645932Medicaid