Provider Demographics
NPI:1760006183
Name:HODGES, MARY L
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:HODGES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 42ND ST E APT 1013
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-6844
Mailing Address - Country:US
Mailing Address - Phone:540-420-4653
Mailing Address - Fax:
Practice Address - Street 1:1515 2ND AVE W APT 1013
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-4108
Practice Address - Country:US
Practice Address - Phone:701-572-6766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1286A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist