Provider Demographics
NPI:1568045144
Name:HODGE, TIERRA DAWN (CDCA 1)
Entity Type:Individual
Prefix:
First Name:TIERRA
Middle Name:DAWN
Last Name:HODGE
Suffix:
Gender:F
Credentials:CDCA 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-4194
Mailing Address - Country:US
Mailing Address - Phone:513-540-9449
Mailing Address - Fax:
Practice Address - Street 1:1221 1ST AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-4194
Practice Address - Country:US
Practice Address - Phone:513-849-2081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH176409324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility