Provider Demographics
NPI:1205861689
Name:HODGE, COLLEEN MARIE
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:HODGE
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 1:2404 STATE HIGHWAY 248
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-9241
Mailing Address - Country:US
Mailing Address - Phone:417-336-5857
Mailing Address - Fax:417-336-3137
Practice Address - Street 1:2404 STATE HIGHWAY 248
Practice Address - Street 2:SUITE 3
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-9241
Practice Address - Country:US
Practice Address - Phone:417-336-5857
Practice Address - Fax:417-336-3137
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001010301225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist