Provider Demographics
NPI:1851762819
Name:HODGE, LYDIA (CEO/PRESIDENT)
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:
Last Name:HODGE
Suffix:
Gender:F
Credentials:CEO/PRESIDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8245 CORDOVA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-2086
Mailing Address - Country:US
Mailing Address - Phone:901-384-1394
Mailing Address - Fax:901-384-1395
Practice Address - Street 1:8245 CORDOVA RD STE 1018245
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-2086
Practice Address - Country:US
Practice Address - Phone:190-138-4139
Practice Address - Fax:901-384-1395
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-15
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL000000012725251C00000X
TNL000000013596253Z00000X
TNL000000021903253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG0092Medicaid