Provider Demographics
NPI:1407413115
Name:HODGE, SHANNON (BA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HODGE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2052 PRINCETON RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45011-4746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2052 PRINCETON RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45011-4746
Practice Address - Country:US
Practice Address - Phone:513-805-2315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH171M00000XMedicaid