Provider Demographics
NPI:1891927547
Name:HODGE, LAURA J (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:J
Last Name:HODGE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 BROOKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4608
Mailing Address - Country:US
Mailing Address - Phone:909-633-0173
Mailing Address - Fax:
Practice Address - Street 1:312 BROOKSIDE AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4608
Practice Address - Country:US
Practice Address - Phone:909-633-0173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-13
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 22367103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical