Provider Demographics
NPI:1437598075
Name:HODGE, DIANE K (LMSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:K
Last Name:HODGE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 SOUTHAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-3926
Mailing Address - Country:US
Mailing Address - Phone:631-235-9165
Mailing Address - Fax:
Practice Address - Street 1:133 SOUTHAVEN AVE
Practice Address - Street 2:
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-3926
Practice Address - Country:US
Practice Address - Phone:631-235-9165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY089208104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker