Provider Demographics
NPI:1942548060
Name:HODGE, MARK GUNTHER (MS,CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:GUNTHER
Last Name:HODGE
Suffix:
Gender:M
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 N 400 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-1913
Mailing Address - Country:US
Mailing Address - Phone:801-714-3505
Mailing Address - Fax:801-714-3520
Practice Address - Street 1:527 W 400 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-1916
Practice Address - Country:US
Practice Address - Phone:801-714-3505
Practice Address - Fax:801-714-3520
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT362373-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870269232033Medicaid