Provider Demographics
NPI:1598378606
Name:HODGE, KATHLEEN ELIZABETH (RADT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:HODGE
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 COTTAGE WAY APT 2
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1941
Mailing Address - Country:US
Mailing Address - Phone:916-856-9265
Mailing Address - Fax:
Practice Address - Street 1:3600 POWER INN RD STE C
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-3826
Practice Address - Country:US
Practice Address - Phone:916-453-2704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1403100820101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)