Provider Demographics
NPI:1568697340
Name:WODKA, RICHARD MARK (MDIV)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:MARK
Last Name:WODKA
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1790 N MASTICK WAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-1135
Mailing Address - Country:US
Mailing Address - Phone:520-223-6910
Mailing Address - Fax:520-281-3548
Practice Address - Street 1:1790 N MASTICK WAY
Practice Address - Street 2:SUITE D
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621-1135
Practice Address - Country:US
Practice Address - Phone:520-223-6910
Practice Address - Fax:520-281-3548
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-21
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral