Provider Demographics
NPI:1447617634
Name:HODGES, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HODGES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3587 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:541-858-8170
Mailing Address - Fax:
Practice Address - Street 1:17710 NE HALSEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-6734
Practice Address - Country:US
Practice Address - Phone:971-293-3468
Practice Address - Fax:971-293-3469
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PROFESSIONALLICENSE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health