Provider Demographics
NPI:1235425620
Name:HODGES, KETTISHA M (LCSW)
Entity Type:Individual
Prefix:
First Name:KETTISHA
Middle Name:M
Last Name:HODGES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MO
Mailing Address - Zip Code:63435-1626
Mailing Address - Country:US
Mailing Address - Phone:573-406-2473
Mailing Address - Fax:
Practice Address - Street 1:2001 MAINE ST. SUITE 102
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-6230
Practice Address - Country:US
Practice Address - Phone:217-740-2719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010028380101Y00000X
IL1490180381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400252568Medicaid